Time (hours)	7	8	9	10	11	12	1	2	3	4	5	6	7	8	9	10	11	12	1	2	3	4	5	7
Observation check
(**See Key) Q1h
Circulation/skin check
Q2h
Food/fluids
Q2h
Elimination (or F for Foley in place)
Q2h
Range of Motion
Q2h
Change in type or number of Restraint (*See Key) Q1h
Staff initials
Key: *Restraints	**Observed Behavior (May use more than one)
NC=No change	CF – Confused; AG – Agitated; VA – Verbally abusive; TF – Tearful; JC – Hallucination; DL – Delusional; A – Patient asleep; SD – Sedated; SB – Subdued; CA – Calm; CO – Cooperative; O – Other
↑3=Increase to 3pt
↑4=Increase to 4pt
↓1=Decrease to 1pt
↓2=Decrease to 2pt
↓3=Decrease to 2pt