General Examination → Nursing Report Generator
Patient & Encounter
Patient name
MRN / ID
Date
Time
Location
General appearance
Select all that apply
Alert & conscious
Drowsy
Restless
Cheerful/Talkative
Unhappy/In pain
Sleepy
Weak
Lethargic
Terminally ill
Breathless
Comfortable
Uncomfortable
ECOG
—
1
2
3
4
5
Speech
Coherent
Slurred/dysarthria
Stuttering/repetition
Aphasia
Nasal voice
Apraxia
Mute-deaf
Hearing
Normal
Tinnitus/Ringing/Buzzing
Deaf
Need hearing aid
Vital signs
BP (mmHg)
Pulse (bpm)
RR (/min)
Temp (°C)
SpO₂ (%)
Other notes
Pain assessment
Score (0–10)
6
Timing
Persistent
On movement
Spontaneous
Episodic
Quality
—
Sharp/Crampy/Stabbing
Dull & aching / Numb
Throbbing/Burning
Colicky/Tingling
Associated symptoms (select any)
Hyperalgesia
Allodynia
Abnormal sensation
Radiating pain
Site
Aggravating/Relieving factors
Respiration
Shortness of breath (SOB)
Pattern
Normal
Mild ↑
Moderate ↑
Severe ↑
Gasping
Cheyne–Stokes
O₂ support / others
Nutrition
Oral intake tolerated
Oral diet
Normal
Soft
Minced
Liquid
Ryle’s/Feeding tube details
GI / GU
Nausea
None
Mild
Moderate
Severe
Vomiting
None
Once
Intermittent
Frequent
Last bowel opened (days)
Stool type (Bristol 1–7)
Urine remarks
Sleep & Medications
Sleep pattern
Sleep well
Unable to sleep
Napping
Medication compliance
Compliant
Not compliant
Medication list / updates
Physical assessment (head to toe)
Head
Eyes
Nose
Mouth
Neck
Skin
Upper limbs
Lower limbs
Genital
Respiratory & Abdomen exam
Lungs: tick all that apply
Clear air entry
Crepitations
Rhonchi
Wheezing
Stridor
Abdomen – inspection
Abdomen – palpation
Abdomen – percussion
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