ABC form Spanish Please enter your Caregiver ID*Please enter your Patient's Admission ID*Patient Name*Clinical ABCDoes your patient have any ABC changes?*-----SELECT-------YesNoMy Patient is:A Acting differently Newly confused, agitated, sleepy Fever or chills B Breathing differently, or coughing Short of breath or more short of breath than usual New or worsening cough C Change in circulation or skin Increase in swelling of arms, legs, face or belly Change in skin? D Diet changes, not eating or drinking as usual E Elimination or bathroom changes More or less urine, dark, blood, mucus or foul smelling Any diarrhea, or no bowel movement for 3 days? F Fall or feeling pain Fallen or has more difficulty standing or walking Feeling new or worse pain G Go take your medications My patient took all of their medications from the end of your last shift until the end of this shift I checked the medication box ActivityDid your patient do Active Range of Motion today?*YesNo Tiptoe Marching Reach Leg lifts Tap dance Core balance Chair rise Did you do pleasurable activities with your patient today?*YesNo Outdoor activities Beauty/pampering Crafts/hobbies/games Socializing Other pleasurable activities Patient InfoWhat is your patients highest spirometry reading?*Please enter a number from 000 to 9999.Spirometry Spirometry not taken What is your patient's Weight?*Please enter a number from 10 to 999.Weight Patient not weighed What is your patients monthly TUGPlease enter a number from 1 to 999.Enter either 1,2, or 3 digits, the first one for minutes and the last 2 for seconds. For example, 1 minute and 30 seconds would be entered as 130TUG TUG not needed Δ
