Shift documentation
CDOC-01
Step 3 of 6 — Wound assessment50%
Vitals & assessments
CDOC-02CDOC-03CDOC-04CDOC-06
Vital signs
CDOC-02
prev 132/80 on 27 Aug
prev 78 bpm
prev 98.0 °F
prev 17 /min
prev 95 %
prev 188 lb
prev 3 / 10
Weight, last 6 visits (lb)
188182022252728
Wound assessment
CDOC-03

Previous 26 Aug: 3.1 × 2.4 × 0.3 cm

6.6 cm²1217212628
Wound photo
CDOC-04
sacrum-26aug.jpg
Attached 26 Aug, 09:41 · Priya Raman, RN
sacrum-21aug.jpg
Attached 21 Aug, 10:05 · Dana Reyes, RN
Structured observations
CDOC-06
Medication & notes
MAR-03CDOC-05CDOC-12
Medications seen in the home
MAR-03

Note any medications you observe in the home that are not on the list, so the list can be reconciled.

Reconcile list
Shift note
CDOC-05CDOC-12
Draft — not signed
Sign-off
CDOC-07CDOC-09CDOC-10
Outstanding items
CDOC-07
12:00 Metformin not recorded
Blocking
Fluid intake not entered
Blocking
Electronic signature
CDOC-09

Signing sets this record read-only. Dana Reyes, RN · 28 Aug 2026, 13:48

Amendments
CDOC-10
Pulse amended 82 → 78 bpm
v2 · 27 Aug 19:55 · Tomas Alvarez, RN · reason: transcription error
Original value 82 bpm
v1 · 27 Aug 18:40 · Tomas Alvarez, RN