TA
Resident:
Training Resident A
Room/Bed:
SIM-01
MRN:
SYNTHETIC-A
DOB/Age:
Fictional training profile
Diet:
Regular, Thin Liquids
Allergies:
NKDA
Monitoring practice — not a medication pass
Fictional training chart · Evening shift
| Order Details / Scheduled Time | Status / Action | Documentation Summary |
|---|---|---|
|
Blood Pressure Check
Monitor BP shiftly. Record values. Parameters: Notify MD if Systolic > 160 or < 95.
|
No entry documented.
Previous Vital Entry05/21/2026 15:00
122 / 78 mmHg
Position: Lying L/Arm
|
|
|
Pulse Rate Monitor
Assess radial pulse rate shiftly.
|
No entry documented.
Previous Vital Entry05/21/2026 15:00
74 bpm
Method: Regular
|
|
|
Temperature Monitor
Record body temperature shiftly.
|
No entry documented.
Previous Vital Entry05/21/2026 15:00
98.4 °F
Method: Forehead (Non-Contact)
|
|
|
Pain Assessment Check
Assess pain level scale 0-10 shiftly. Document score.
|
No entry documented.
Previous Vital Entry05/21/2026 15:00
0 (No Pain)
|
|
|
Routine Bowel Prompt: Stools count
Document number of bowel movements this shift. [Prompt ID: 8407870]
|
No bowel prompt documented. | |
|
Routine Order Prompt: Treatment Effective?
Document clinical treatment effectiveness. Y / N. [Prompt ID: 8407869]
|
No treatment effectiveness documented. | |
|
Anticoagulant Prompt: Bleeding observed?
Evaluate for active bleeding, epistaxis, or hematuria. Y / N. [Prompt ID: 8408101]
|
No prompt documented. | |
|
Anticoagulant Prompt: New bruising or ecchymosis?
Inspect skin integrity. Note any new bruises. Y / N. [Prompt ID: 8408102]
|
No prompt documented. | |
|
Anticoagulant Prompt: Epistaxis (Nosebleed) observed?
Evaluate for active or recent nosebleeds. Y / N. [Prompt ID: 8408103]
|
No prompt documented. | |
|
Anticoagulant Prompt: Hematuria observed?
Assess urine clarity. Note pink, red, or tea-colored urine. Y / N. [Prompt ID: 8408104]
|
No prompt documented. | |
|
Anticoagulant Prompt: Dark or tarry stools?
Monitor stools for active bleeding or melena. Y / N. [Prompt ID: 8408105]
|
No prompt documented. | |
|
Psychotropic Prompt: Target behavior occurrence?
Evaluate for target psychiatric behaviors (verbal agitation, physical aggression). Y / N. [Prompt ID: 8409201]
|
No prompt documented. | |
|
Psychotropic Prompt: Increased Sedation or Somnolence?
Assess alertness during shift. Note excessive drowsiness. Y / N. [Prompt ID: 8409202]
|
No prompt documented. | |
|
Psychotropic Prompt: Dry mouth reported?
Monitor for anticholinergic side effects. Y / N. [Prompt ID: 8409203]
|
No prompt documented. | |
|
Psychotropic Prompt: Blurred vision experienced?
Assess for transient visual changes. Y / N. [Prompt ID: 8409204]
|
No prompt documented. | |
|
Psychotropic Prompt: Tremors / EPS observed?
Observe for pill-rolling tremors, muscular rigidity, or shuffling gait. Y / N. [Prompt ID: 8409205]
|
No prompt documented. |