FAMILY NAME MRN FAMILY NAME MRN

GIVEN NAME MALE FEMALE GIVEN NAME MALE FEMALE

D.O.B. _______ / _______ / _______ M.O. D.O.B. _______ / _______ / _______ M.O.

STANDARD ADULT ADDRESS

STANDARD ADULT ADDRESS
GENERAL OBSERVATION CHART GENERAL OBSERVATION CHART
¶SMRÊ+Î*|Ä
Altered Calling Criteria LOCATION Altered Calling Criteria LOCATION
SMR110010

ALL OBSERVATIONS MUST BE GRAPHED COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE ALL OBSERVATIONS MUST BE GRAPHED COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Date Date Date Date
Time Time Time Time
41 41
35 35
40.5 40.5
Respiratory Rate

30 30 40 40
25 25

•
39.5
AIRWAY/BREATHING

39.5
20 20 39 39

Temperature (0C)
EXPOSURE
38.5 38.5
15 15 38 38
10 10 37.5 37.5
5 5 37 37
36.5 36.5
36 36
100 100 35.5 35.5
95 95 35 35
SpO²%

90 90 34.5 34.5
34 34
85 85
Assess pain level at rest and with movement. Enter R for at rest, M for movement
O²Lpm O²Lpm
Oxygen

Device / Device / Severe

Severe (7-10) (7-10)
mode mode

Pain
Moderate
Key: RA = Room Air, NP = Nasal Prongs, FM = Simple facemask, NRB = Non Re-breather, VM = Venturi Mask Moderate (4-6) (4-6)
Mild
Mild (1-3)
BINDING MARGIN - NO WRITING
Holes punched as per AS2828.1:2012

230 230 (1-3)

> <

220 220 Nil No pain

210 210
Initials Initials
200 200
Blood Pressure (mmHg) SBP is trigger

Date Date

Weight Bowels Blood Glucose

190 190
180 180
170 170 Time Time
160 160
150 150 BGL BGL
140 140 Date Date
130 130
120 120
110 110 Date Date
100 100
90 90 Daily Daily
80 80
Date Date
70 70
CIRCULATION

60 60
50 50 Time Time
40 40
Rhythm Rhythm SG SG

160 160
pH pH
150 150
140 140
Leuk Leuk
130 130
•

120 120
Heart Rate

Urinalysis

110 110 Blood Blood

100 100
90 90 Nitrite Nitrite
80 80
70 70 Ketones Ketones
60 60
50 50 Bilirubin Bilirubin
40 40
A A U/Bil U/Bil
Neurological
DISABILITY

V V
221113

P P Protein Protein
U U
NH606512

Enter appropriate letter. A= Alert, V= Rousable by voice (conduct GCS). P= Rousable only by pain (conduct GCS). U= Unresponsive
Glucose Glucose

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STANDARD ADULT GENERAL OBSERVATION CHART - NH606512 - 221113.indd 1 22/11/2013 5:17:20 PM

 FAMILY NAME MRN

GIVEN NAME MALE FEMALE

REFER TO YOUR LOCAL CLINICAL EMERGENCY RESPONSE SYSTEM (CERS) PROTOCOL
D.O.B. _______ / _______ / _______ M.O.
FOR INSTRUCTIONS ON HOW TO MAKE A CALL TO ESCALATE CARE FOR YOUR PATIENT
STANDARD ADULT ADDRESS
GENERAL OBSERVATION CHART CHECK THE HEALTH CARE RECORD FOR AN END OF LIFE CARE PLAN
WHICH MAY ALTER THE MANAGEMENT OF YOUR PATIENT
Altered Calling Criteria LOCATION

ALL OBSERVATIONS MUST BE GRAPHED COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Yellow Zone Response
*
OTHER CHARTS IN USE IF YOUR PATIENT HAS ANY YELLOW ZONE OBSERVATIONS OR ADDITIONAL CRITERIA YOU MUST
Neurological Observation Insulin Infusion Alcohol Withdrawal 1. Initiate appropriate clinical care
Fluid Balance Pain / Epidural / Patient Control Analgesia Resuscitation Plan 2. Repeat and increase the frequency of observations, as indicated by your patient’s condition
Anticoagulant Neurovascular Other ___________
3. Consult promptly with the NURSE IN CHARGE to decide whether a CLINICAL REVIEW (or other CERS) call
PRESCRIBED FREQUENCY OF OBSERVATIONS should be made
Consider the following:
Observations must be performed routinely at least 8th hourly, unless advised below
• What is usual for your patient and are there documented ‘ALTERATIONS TO CALLING CRITERIA’?
DATE: dd/MM/yy
Time: hh:mm EXAMPLE • Does the trend in observations suggest deterioration?
• Is there more than one Yellow Zone observation or additional criterion?
Frequency Required Twice daily • Are you concerned about your patient?

Medical Officer Name (BLOCK letters) P. SMITH

IF A CLINICAL REVIEW IS CALLED:
1. Reassess your patient and escalate according to your local CERS if the call is not attended within 30 minutes
Medical Officer Signature P. SMITH or you are becoming more concerned
2. Document an A-G assessment, reason for escalation, treatment and outcome in your patient’s health care record
Attending Medical Officer Signature R. Bloggs
3. Inform the Attending Medical Officer that a call was made as soon as it is practicable
ALTERATIONS TO CALLING CRITERIA
MUST BE REVIEWED WITHIN 72 HOURS OR EARLIER IF CLINICALLY INDICATED
*•Additional YELLOW ZONE Criteria

BINDING MARGIN - NO WRITING

Holes punched as per AS2828.1:2012
Any alterations MUST be signed by a Medical Officer and confirmed by Attending Medical Officer Increasing oxygen requirement • Greater than expected fluid loss from a drain
Document rationale for altering CALLING CRITERIA in the patient’s health care record
• Poor peripheral circulation • New, increasing or uncontrolled pain
DATE: dd/MM/yy • Excess or increasing blood loss (including chest pain)
TIME: hh:mm • Decrease in Level of Consciousness or new onset of confusion • Blood Glucose Level < 4mmol/L or > 20mmol/L
Next review due dd/MM/yy • Low urine output persistent for 4 hours with no decrease in Level of Consciousness
Date & Time hh:mm (< 100mLs over 4 hours or < 0.5mL/kg/hr via an IDC) • Ketonaemia > 1.5mmol/L or Ketonuria 2 + or more
Yellow Zone 30-34 • Polyuria, in the absence of diuretics • Concern by patient or family member

STANDARD ADULT GENERAL OBSERVATION CHART SMR110.010

Respiratory Rate (urine output > 200mL/hr for 2 hours) • Concern by you or any staff member
Red Zone > 35

Yellow Zone CONSIDER IF YOUR PATIENT’S DETERIORATION COULD BE DUE TO

SpO2 SEPSIS, A NEW ARRHYTHMIA, HYPOVOLAEMIA/HAEMORRHAGE, PULMONARY EMBOLUS/DVT,
EXAMPLE

Red Zone PNEUMONIA/ATELECTASIS, AN AMI, STROKE, OR AN OVERDOSE/OVER SEDATION

Yellow Zone
Heart Rate
Red Zone
Red Zone Response
IF YOUR PATIENT HAS ANY RED ZONE OBSERVATIONS OR ADDITIONAL CRITERIA # YOU MUST CALL FOR A
Yellow Zone RAPID RESPONSE (as per local CERS) AND
Blood Pressure 1. Initiate appropriate clinical care
Red Zone 2. Inform the NURSE IN CHARGE that you have called for a RAPID RESPONSE
Yellow Zone
3. Repeat and increase the frequency of observations, as indicated by your patient’s condition
Other 4. Document an A-G assessment, reason for escalation, treatment and outcome in your patient’s health care record
Red Zone 5. Inform the Attending Medical Officer that a call was made as soon as it is practicable
Medical Officer Name (BLOCK letters) P. SMITH #Additional RED ZONE Criteria
Medical Officer Signature P. SMITH • Cardiac or respiratory arrest
• Sudden decrease in Level of Consciousness

SMR110010
¶SMRÊ+Î*|Ä
Attending Medical Officer Signature R. Bloggs • Airway obstruction or stridor (a drop of 2 or more points on the GCS)
• Patient unresponsive • Seizures
INTERVENTIONS / COMMENTS / ACTIONS
• Deterioration not reversed within 1 hour of Clinical Review • Low urine output persistent for 8 hours
Date Time • Increasing oxygen requirements to maintain oxygen (< 200mLs over 8 hours or < 0.5mL/kg/hr via an IDC)
saturation > 90% • Blood Glucose Level < 4mmol/L or > 20mmol/L with
1. a decreased Level of Consciousness
• Arterial Blood Gas: PaO2 < 60 or PaCO2 > 60 or
2. pH < 7.2 or BE < -5 • Lactate ≥ 4mmol/L
• Venous Blood Gas: PvCO2 > 65 or pH < 7.2 • Serious concern by any patient or family member
3. • Only responds to Pain (P) on the AVPU scale • Serious concern by you or any staff member
4.

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