Symptom Record Log
Patient name _________________________________________
Instructions
Use this chart daily to record the symptoms that you are experiencing. Rate the symptoms according to severity using a scale of 1 to 4 (see below). Under Interventions, record what you did for relief, and under Comments, whether or not it helped. Share this log with your nurse or doctor each week.
|
Codes for symptoms:
F=Fever
C=Chills
HA=Headache
M=Muscle aches
J=Joint pain
NC=Nasal congestion or cough
|
Severity rating for symptoms:
1=Able to carry on daily activities normally
2=Symptoms mildly affect my day
3=Severe symptoms, but gained relief after intervention
4=Severe symptoms with no relief gained
|
|
|
Date
|
Symptoms
|
Rating
|
Interventions
|
Comment
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Phone numbers
|
|
Nurse:
|
_________________________
|
Phone:
|
_____________
|
|
Doctor:
|
_________________________
|
Phone:
|
_____________
|
|
Other:
|
_________________________
|
Phone:
|
_____________
|
|
Comments:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Patient's signature:
|
_________________________
|
Date
|
_____________
|
|
Nurse's signature:
|
_________________________
|
Date:
|
_____________
|
Online Medical Reviewer:
Bass, Pat F. III, MD, MPH
Online Medical Reviewer:
Fraser, Marianne, MSN, RN
Last Review Date:
11/10/2012
Copyright © 2003 by Jones & Bartlett Publishers, Inc. and its licensors. All rights reserved.