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					    Behavioral Event Assessment/Progress Note

  Person Completing:_____________________
  Date and Time of Event:______________________                               Location of Event:________________________________
s Summary of event:

B Vital Signs:      B/P__________                P______       R______        T______       O2 Sat________%               BG (if diabetic)________mg/dl

                      Use of PRN medication          Effective      Yes       No
                      Name, dose, and time PRN medication given:______________________________________________________

A Neurological status:
                  Alert      Oriented to    person                    place        time
                  Change in mentation from baseline                   No         Yes          No
                                                                                Yes - please describe:__________________________

                  Resident c/o pain (verbally or behaviorally)                   Resident new onset of incontinence
                  Resident c/o dizziness                                         Resident c/o symptoms of UTI
                  Resident c/o too hot / too cold                                Resident hallucinating (experiencing something not there)
                                                                                    Seeing something           Feeling something
                                                                                    Hearing something          Smelling something
                  Resident started new medication within last 24-48 hours? (if checked, complete information below)
                  Name and sig of new medication:_____________________________________________________________
                  Date and time of last dose:____________________
                  Resident had abnormal labs within last 2 days (if checked, complete information below)
                  Explain abnormal labs present:________________________________________________________________

    Head to toe assessment (visible signs of injury):_______________________________________________________________

    First Aid/Response (if injured):

    Medical Staff notified:          Yes         No            Date:_____________           Time:_____________

R                 Orders received:         Yes         No      MD/NP Name:___________________________________________________

    Environmental: Were any of the following present at the time of the event? (check all that apply)
              New caregiver            New room/unit                                   New furniture
              Clutter                  New roommate                                    Rearranged furniture
              Glare on floor           Poor lighting*                                  Loud noise, too much noise; busy environment
              Other                    *Note: adequate lighting is defined as lighting that is adequate for the resident to facilitate best vision.

    Resident Behaviors: Were any of the following behaviors present at the time of the event? (check all that apply)
               Resident stealing *                                            Verbally abusive (shouting, name calling, etc.) *
               Resident self abusive; expressing self-harm *                  Physically abusive (pushing, hitting, biting, etc.) *
               Inappropriate dressing /undressing *                           Resident eloped*/exited unit *
               Repetitive behavior                                            Sexually inappropriate behavior *
               Describe:_________________________________                     Describe:_________________________________

                                                                    File in Medical Record
* Report findings to administrator

Resident: Were any of the following triggers present at the time of the event? (check all that apply)
           Resident injured                                                 Frustrated from complicated tasks
           Resident c/o pain (verbally or behaviorally)                     Frustrated from inability to communicate
           Resident c/o dizziness                                           Resident rummaging through others' belongings
           Resident c/o too hot / too cold                                  Resident not wearing hearing aide or faulty hearing aide
           Resident c/o hunger                                              Resident experiencing poor sleep pattern
           Resident not wearing glasses or dirty glasses                    Resident delusional (false idea, paranoid)
           Resident in crowd                                                Resident wandering/pacing/exit seeking? Why?
           Resident alone                                                       Lost                      Looking for someone
           Resident incontinent                                                 Confused                  Going to work
           Resisting care                                                       Other:_____________________________________
           Resident crying
           Resident needing to use bathroom? (if checked, complete information below)
           Last time voided:_____________          Last bowel movement:_________________
           Resident diabetic?        Time of last meal:_____________ Meal consumption:__________
New Interventions (check all that apply):
              Decrease noise              Discourage daytime napping (sundowners)            Pain management assessment
              Increase lighting          Wears properly functioning hearing aide             Therapy referral for ___________________
              Duplicate items               Audiology referral                               SLP referral for identification of cognitive
              Redirection                Wears clean glasses                              deficits and best way to communicate
              Exercise group                Vision referral                                  Dietary referral for c/o hunger; evaluate
              Do not argue               Increase frequency of toileting                  decrease caffeine; evaluate decrease sugar
              Limit choices to 2         Simple, one step directions                         Educate staff re:_____________________
              Label environment with picture/word signs, large print, etc
              Remove clutter and simplify environment (where able)                           Supervision while____________________
              Insert items from home if available                                            Activity referral for relaxation, redirection
              Tactile cue (especially if hallucinating)                                      Medical staff referral for _______________
              Alter environment to remove hallucination stimuli                              Pharmacy referral for medication review
              Use repetitive behavior as exercise/activity/task                               Social Service referral
              Secure exit seeking trigger items                                               Mental Health referral
              Speak slowly; one sentence at a time.                                          Restorative nursing referral for __________
              Secure environment (remove dangerous items, etc.)                              Temporary 1:1 attention
              Plastic tableware                                                              Suicide precautions
              Other______________________________________________                            Environmental changes to deter exit seeking

Responsible party notified:               Yes        No         Date:_____________       Who:_______________________________

Nurse Signature:________________________________                Date:_____________

Interdisciplinary Team Review:        Date:____________________

                                                          File in Medical Record