Daily Early Mobility Data Collection Tool Hospital ID# ___________ Unit ID#___________ Date (mm/dd/yyyy) ___________ Fill out Fill out if patient is intubated or has tracheostomy (trached) and is mechanically ventilated for all (can use for patients not mechanically ventilated) beds Bed Intub/ Date of Sedation Scale Delirium Assessment Highest PT OT Events (Up to Three Events) # Trach Intubation Level of Barrier 0 to 25 RASS/ CAM-ICU/ ASE & (mm/dd/yyyy) to (see daily codes on next page) SAS/ Mech 0 to ASE/ ICU 0–10, P, N, X, – Not Used in Vent If RASS 5 8 a 1 Event 2 Event 3 X, – ICDSC/ P, N, UTA, Unit to 4, NS or (see Higher Required Only if Only if UTA, X, NU NK X, NK daily Level of Needed Needed NK UTA, If SAS codes Mobility NK – 1 to 7, NS or on next – X, NK page) 0 to 15 (see daily codes on next page) Y N E / / RASS SAS C A I NU Y N Y N NU NK NK Y N E / / RASS SAS C A I NU Y N Y N NU NK NK Y N E / / RASS SAS C A I NU Y N Y N NU NK NK Y N E / / RASS SAS C A I NU Y N Y N NU NK NK Y N E / / RASS SAS C A I NU Y N Y N NU NK NK Y N E / / RASS SAS C A I NU Y N Y N NU NK NK
Daily Early Mobility Data Collection Tool Hospital ID# ___________ Unit ID#___________ Date (mm/dd/yyyy) ___________ Fill out for all beds Fill out if patient is intubated or has tracheostomy (trached) and is mechanically ventilated (can use for patients not mechanically ventilated) Bed # Intub/ Trach & Mech Vent Date of Intubation (mm/dd/yyyy) Sedation Scale Delirium Assessment Highest Level of – 0 to 8 (see daily codes on next page) Barrier to a Higher Level of Mobility – 0 to 15 (see daily codes on next page) PT OT Events (Up to Three Events) 0 to 25 (see daily codes on next page) RASS/ SAS/ Not Used in Unit CAM-ICU/ ASE/ ICDSC/ NU P, N, X, UTA, NK ASE 0–10, X, UTA, NK P, N, X, UTA, NK If RASS – 5 to 4, NS or X, NK 1 Required Event 2 Only if Needed Event 3 Only if Needed If SAS – 1 to 7, NS or X, NK Y N E / / RASS SAS NU C A I NU Y N NK Y N NK Y N E / / RASS SAS NU C A I NU Y N NK Y N NK Y N E / / RASS SAS NU C A I NU Y N NK Y N NK Y N E / / RASS SAS NU C A I NU Y N NK Y N NK Y N E / / RASS SAS NU C A I NU Y N NK Y N NK Y N E / / RASS SAS NU C A I NU Y N NK Y N NK ICU
early-mobility-tool.docx