CLINICAL ASSESSMENT TOOL

Subjective Data (Basic Conditioning Factors)

Student: Date of Care:

Patient’s Initials: Age:

Room #: Allergies:

Food:

Gender: Medications:

Environmental:

Admitting Diagnosis:

Secondary Diagnosis:

Developmental Stage (Erickson and Havinghurst, see Perry and Potter):

(List Developmental stage and tasks, assess each task)

History of present illness:

Past medical history (Include Date):

Past surgical history (Include Date):

Medications:

Drug Name Dose Route Frequency Classification

Complementary/Alternative Medical Practices

Herbal Remedies:

Vitamins/Minerals:

Meditation/Yoga

Massage:

Acupuncture/Acupressure:

Aromatherapy:

Other:

Health care system (Current orders and role of health care members):

Sociocultural / spiritual orientation:

Family system:

Patterns of Living:

A. Employment:

B. Education:

C. Hobbies / interest:

D. ETOH / drug use

Environment (Conditions of living and working):

Available Resources (Economic, personal, agencies):

Laboratory and Diagnostic Test (give results and significance of abnormals)

Objective Assessment of the USCR's

Please use Y, N, NA to indicate Yes, No or Not Applicable

	Day 1	Day 2	Additional Data
Psychosocial Solitude v. Social Interaction or Normalcy
Well groomed/Good hygiene
Appropriate/Full range affect
Maintains eye contact
Calm mood
Cooperative attitude
Able to concentrate
Clear speech (volume/tone)
Psychomotor retardation
Tics/Tremors
Hyperactivity/Restlessness/Agitation
Hallucinations/Illusions
Suicidal/Homicidal Ideations
Activity/Rest
Well-rested
Fatigued
Slept through night
Neuromuscular (prevention of hazards)
Alert and oriented
Gait steady
Hygiene independent
Pain free
Hand grasp, strong and equal bilat
Foot push, strong and equal bilat
Smile symmetrical
Tongue to midline
PERL
Meets developmental task
Cardiovascular (air or water)
Palpable pedal pulses bilaterally
Oral mucosa pink
Conjunctiva pink
Capillary refill within 2 seconds
Absence of edema
Apical/radial regular rhythm			Rate=
Blood pressure			BP=
Telemetry
Integument (prevention of hazards)
Temperature			Temp=
Skin turgor WNL
Skin warm to palpation
Skin intact
Incisions
Wounds