ADDRESSOGRAPH
ENTER
DATE, RN
INITIALS,
AND LAST
FOUR SSN
ACUITY
CODE
SECTION I - CRITICAL INDICATORS
POINT
VALUES
1. VITAL SIGNS
(Manual TPR, BP)
100
101
102
103
104
105
Vital signs qid or less
Vital signs q4h or x 6
Vital signs q3h or x 8
Vital signs q2h or x 12
Vital signs q1h or x 24
Tilt test q4h or more
1
2
3
4
8
2
106
107
108
109
110
Intake and output q8h
Circulation checks q2h or x 12
Patient checks q30 minutes x 8
Patient checks q15 minutes x 8
Neuro checks q4h or x 6
2
2
8
16
3
3. ACTIVITIES OF DAILY LIVING
Care - age 6 or more - Self/Minimal
Care - age 6 or more - Assisted
Care - age 6 or more - Complete
111
112
113
2
6
14
SUBTOTAL A POINT VALUE
ENTER DATE, RN INITIALS,
AND LAST FOUR SSN
ACUITY
CODE
SECTION I - CRITICAL INDICATORS
(Continued)
POINT
VALUES
5. TREATMENTS/PROCEDURES/MEDICATIONS
Start IV/Ace wraps/Tube care
Dressing - simple 5-7 mins x 2
Dressing - complex 30 mins x 1
Lab tests performed/collected on the unit x 3
Do EKG
Venipuncture, arterial puncture x 2
Medications - exclude IV - 3-11 trips or q3h - q8h
Medications - exclude IV - 12 trips or more or
q2h
Restraints, 2 point, 4 point, Posey
New admission - assessment and orientation
Transfer - between psychiatric units
(receiving units only)
Accompany patient off unit - 15 minutes
Accompany patient off unit - 30 minutes
Accompany patient off unit - 45 minutes
Other activities - 15 minutes
Other activities - 30 minutes
Other activities - 45 minutes
Each hour requiring continuous staff attendance
2
2
4
2
2
2
2
4
2
12
4
2
4
6
2
4
6
8
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
WORKLOAD MANAGEMENT SYSTEM FOR
NURSING - PSYCHIATRIC WORKSHEET
SUBTOTAL B POINT VALUE
DD Form 2552, FEB 92 (EG)
Replaces DD Form 2552 TEST, NOV 89, which may be used.
Page 1 of 2 Pages
Designed using Perform Pro, WHS/DIOR, Sep 94
2. MONITORING
4. FEEDING
Spoon feed or 1:1 at meals tid
Tube feed - bolus q4h or x 6
Escort patient to dining hall x 1
114
115
116
6
5
2
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