OVI Children's Hospital Initial Evaluation and Care Plan Form
Step 1: Patient Information
Patient Name
Date
Age/DOB
MRN/ID
Provider Name
Reason for seeking treatment
Summary of social background or specific vulnerabilities that qualify patient for assistance
Step 2: Clinical Status Evaluation
Vital Signs
Temperature (°C)
Weight (kg)
Heart Rate (bpm)
Respiratory Rate
SpO2 (%)
General Examination
Skin Color/Condition
Edema
Present
Absent
Nutritional Status
Adequate
Malnourished
Signs of Pain (e.g., grimacing)
Hydration and Pain
1. Hydration Status
Adequate
Mild dehydration
Severe dehydration
2. Pain Level (Scale 0-10)
a. Location of Pain
Mobility
Independent
Partial assistance required
Fully dependent
2. Systemic Assessment
System
Normal/Abnormal
Comments
Respiratory
Normal
Abnormal
Cardiovascular
Normal
Abnormal
Neurological
Normal
Abnormal
Gastrointestinal
Normal
Abnormal
Musculoskeletal
Normal
Abnormal
Skin/Wounds
Normal
Abnormal
3. Ongoing Medical History and Needs
Primary Diagnosis
Secondary Diagnosis
Known Chronic Conditions
Current Medications
Allergies
Step 3: Daily Living and Therapy Needs
Activities of Daily Living (ADLs)
Activity
Level of Assistance
Comments
Bathing
None
Partial
Full
Dressing
None
Partial
Full
Eating
None
Partial
Full
Mobility/Transfers
None
Partial
Full
Toileting
None
Partial
Full
Therapies Needed
Physical Therapy
Psychiatric/Trauma Support
Virtual Reality Therapy / Play Therapy
Other:
Step 4: Social and Emotional Well-Being
Factor
Observation
Comments
Emotional State
Stable
Unstable
Engagement in Activities
High
Moderate
Low
Interaction with Peers
Positive
Neutral
Negative
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