Clinical Assessment Form

8/11/2019 Clinical Assessment Form

1/17

Clinical Assessment Form

Tab: ADLs

ADL Assessment Date and Time

ADL AssessmentCheck all that apply

Bed mobility

Transfer

Walking

Dressing

Eating

Toilet Use

Personal hygiene

Bathing

Subtab: GU

Urine Odor

Speech Assessment

Check all that applyRate Fluency

Rhythm Quantity

Content Articulation

Loudness Pattern

Notes:

Mood and Behavior

Verbal expression of distress Anxious

Loss of interest Sad appearance

Sleep pattern disturbance Appropriate or patient

Apathetic

Urine Color

Check one

Yellow

Amber

Orange

Brown

Red

Pink

Green

Blue

Not Visualized

Urine Character

Check one

Clear

Cloudy

Concentrated

Dilute

Sediment

Bloody

Clots

Frothy

Purulent

Urinary Symptoms

Check one

Dysuria

FrequencyUrgency

Oliguria

Polyuria

Anuria

Incontinence, Stress

Incontinence, Complete

Incontinence, Daytime

Incontinence, Nighttime

Hematuria


2/17

Subtab: Integumentary: Braden Scale

Subtab: Integumentary: Chart Site/Wound

Description

Dressing Treatment

Color and Texture

Cyanosis Bronzing

Erthema Bruising

Pallor Leathery

Jaundice Photosensitivity

Nocturia

Urinary Retention

Diffculty Starting Stream

Hesitancy

Catheter

Date/time inserted

Catheter Size (Fr)

Volume In Balloon (mL) N/A

Sensory Perception

Check one

Completely Limited

Very Limited

Slightly Limited

No Impairment

Nutrition

Check one

Very Poor

Probably Inadequate

Adequate

Excellent

Mobility

Check one

Completely Immobile

Very Limited

Slight Limited

No Limitations

Activity

Check one

Bedfast

Chairfast

Walks Occasionally

Walks Frequently

Moisture

Check one

Constantly Moist

Often Moist

Occasionally Moist

Rarely Moist

Friction

Check one

Shear Problem

Potential Problem

No Apparent Problem


3/17


4/17

Subtab: Mental Health

Behavior / Affect

Check all that apply

Appropriate

Agitated

Anxious

DepressedCrying

Fearful

Hostile

Help-rejecting/complaining

Inappropriate

Embarrassed

Evasive

Resentful

Angry

Negativistic

ImpulsiveDisturbed sleep

Nightmares

Night terrors

Regression

Other:

Stressors


Condition

Hospitalization

Diagnosis

ProcedureFamily Death

Family Illness

Family Problems

Finances

Surgery

Unknown Causes

Abuse/Neglect

Exposure to violence

Familial substance abuse

Developmental disabilities in caregivers

Impulsive acting outHistory of DSS involvement

History of juvenile services involvement

Other:

Coping


Well

Fair

Poor

Ineffective


5/17

Communication


Verbal

Nonverbal

Blocking

CimcumstantialityFlight of ideas

Perseveration

Verbigeration

Neologism

Mutism

Acceptance

Thoughts exhibitedCheck all that apply

Delusional (If chosen, check all boxes below that apply)

Reference or persecution

Alien control

Nihilistic

Self-deprication

Grandeur

Somatic delusion

Hallucinatory (If chosen, check all boxes below that apply)

Auditory

VisualOlfactory

Gustatory

Tactile

Depersonalization

Obsessive

Stereotyped

Consistent reactions

Inconsistent reactions

Reaction


Over-reactive

Under-reactive

Purposeful

Disorganized

Stereotyped

Coping Style


Acting out Passive aggression

Affiliation Projection

Altruism Protective identification

Anticipation RationalizationAutisitic fantasy Reaction formation

Denial Repression

Devaluation Self-assertion

Displacement Self-observation

Dissociation Splitting

Humor idealization Sublimation

Intellectualization Supression

Isolation of affect Undoing

Omnipotence


6/17

Consistent reactions

Inconsistent reactions

Subtab: Musculoskeletal

Subtab: Vascular Access

Level of orientation


Confusion

Clouding of confusion

Stupor

Delirium

Acute brain syndrome

Dream state, coma

Memory disorders presentMuscle Tone / Strength: Check each column

All LUE RUE LLE RLE

Motor Strength Grade: Check all that apply5 / 5

4 / 5

3 / 5

2 / 5

1 / 5

0 / 5

Range of Motion: Check all that apply

Full ROM

Impaired ROM

Characteristic: Check One per column

Spasm

Paralysis

Atrophy

Musculoskeletal

Symptoms


Pain

Joint Swelling

Joint Stiffness

Contractures

Deformities

Crepitus

WeaknessAmputation

Fractures

Spasms

Weight Bearing / Gait

None


Steady

Independent

UnsteadyDependent

Asymmetrical

Jerky

Shuffling

Spastic

Developmentally

appropriate

Lordosis

Scoliosis

KyphosisN/A

Devices

Cast

Leg braces

Back brace

Boot

Sling

Cane

Crutches

Walker

Wheelchair

Chairfast

Bedfast

Prothesis

Other:

N/A

Assessment Date and Time

Location


7/17

Subtab: Pain Scale

Pain Duration

Pain Frequency Constant Intermittent

Type of Pain Acute

Chronic Cancer-Related

Pain Goal Notes:

Aggravating Factors

Movement Coughing Breathing Eating

Aggravating Factors Comments:

Type

Select one:

Peripheral IV

Central Line, Single Lumen

Central Line, Double Lumen

Central Line, Triple Lumen

Arterial Line,

Groshong

AV fistula

Port, Implanted

Tunneled

Power Port

Single Lumen PICC

Double Lumen PICC

Size

Pain Location

Onset

Pain Goal

Check one

0 1 2 3 4 5 6 7 8 9 10


8/17

Alleviating Factors

Rest Compression Medication Ice Immobility

Alleviating Factors Comments:

Subtab: Cardio

Pain Rating

Check one

0 1 2 3 4 5 6 7 8 9 10

Quality Of Pain


Aching

Burning

Throbbing

Piercing

Dull

SoreStabbing

Crushing

Heart Tones

Check all that apply Radiating

S1, S2 Murmur Gallop

Regular S3 Muffled

Irregular S4 Distant

Pulses

Check one per column

All LUE RUE LLE RLE

Absent

Intermittent+ 1

+ 2

+ 3

Bounding

DopplerCapillary Refill


All LUE RUE LLE RLE

< 3 sec

> 3 sec

Absent

Edema


All LUE RUE LLE RLE

Absent

Trace1+

2+

3+

4+

NonPitting

Pitting

Anasarca

Skin Color and Description


9/17

Subtab: Respiratory

Airway Device


ETT Tracheostomy

Nasopharyngeal Mask Nasal Trumpet

Laryngeal Mask Oral Airway

Has Mechanical Device? If so, check one:


Appropriate for ethnicity Clammy Flushed Pale

Warm Cyanotic Fragile Ashen

Dry Diaphoretic Jaundiced

Intact Blotchy Moist

Cool Dusky Mottled

Skin Color and Description: Details

Devices


Pacer

IABP

CVP

Pulmonary Artery Monitoring

Cardiac Monitor

Arterial Line

Vasoactive Drips

Rate Of Drip

Methods

Chose one

Room Air %

Nasal Cannula L/minSimple Face Mask %

Mist tent %

Trach Collar %

T-Piece %

Ambu Bag %

NRB mask %

CPAP %

BiPAP %

Blow-by %

Other (specify)


10/17

Assist Control Pressure Controlled Ventilation

Intermittent mandatory

ventilation

High Frequency Ventilator

Synchronized intermittent

ventilation

Oscillator

Pressure support ventilation VRD4

Positive Pressure Ventilation Other:

Volume Controlled VentilationRate

(breaths

per

minute:

Tidal Volume (Ml

per inspiration):

Positive End

Expiratory

Pressure:

Sputum


Color Amount

Copious Yellow Serosanguinous

Bloody Purulent NoneSerous Black Thin

White Brown Tenacious

Creamy Tan Moderate

Green Blood Tinged

Clear

Respiratory Symptoms


Cough Hyperventilating Nasal Drainage

Shortness of Breath Decreased Smell Difficulty Breathing withActivityDifficulty Breathing at Rest Deformity

Cyanosis Epistaxis Other:

Hypoventilating Use of Accessory Muscles

Breath Sounds

Right Upper Lobe, Check all that apply

Clear Coarse Absent

Rales Inspiratory Stridor

Crackles Expiratory Anterior

Rhonchi Decreased Posterior

Wheeze Diminished

Left Upper Lobe, Check all that apply

Clear Coarse Absent




Wheeze Diminished


11/17

Right Middle Lobe, Check all that apply

Clear Coarse Absent




Wheeze Diminished

Left Lower Lobe, Check all that apply

Clear Coarse Absent




Wheeze Diminished

Right Lower Lobe, Check all that apply

Clear Coarse Absent

Rales Inspiratory StridorCrackles Expiratory Anterior


Wheeze Diminished

Respirations: Select all that apply Grunting

Regular Labored Retracting

Irregular Gasping Nasal Flaring

Subtab: GIGI Symptoms


Anorexia

Belching

Vomiting

Heartburn

Nausea

Epi. Pain

Cramping

Constipation

DiarrheaAbd. Pain

Flatulence

Hiccup

Incontinence

Early Satiety

Dysphagia

Encopresis

Bloody stools

Weight change

Abdominal Description


All LUQ RUQ LLQ RLQ

Soft

Flat

Non Distended

Non Tender

Firm

DistendedRound

Rigid

Sunken

Tender

Guarding

Rebound

Scars

Hernia

Diet Tolerance

Check one

Excellent

Adequate

Inadequate

NPO

Other

N/A


12/17

Bowel Sounds


All LUQ RUQ LLQ RLQ

Present

Hypoactive

Hyperactive

Absent

Stool

Color

Check one

Brown

Black

Blood, Frank

Blood Tinged

Clay

Green

Maroon

Yellow

Tan

Emesis

Description

Check one

Clear

Frothy

Bilious

Green

Bloody

Blood Tinged

Coffee Ground

Food Content

Projectile

Stool/Description

Soft Mucous

Semisoft Large

Hard Small

Liquid Pasty

Formed Seedy

Frothy Tarry

Clots Watery

Loose

Last Bowel Movement

Gastric Tubes

Location

Check one

Nasogastric, Left Nare

Nasogastric, Right Nare

Orogastric

Gastric

Nasoduodenal tube

Gastric Tubes

Draining

Check one

Capped

Gravity

Low Intermittent Suction

Continuous Suction

Gastric Tubes

Size Depth Measure At

Size (Fr) Nare

Lip

Depth (cm) Teeth

Skin Insertion

Ostomy

Location

LUQ

LLQ

RUQ

RLQ

Ostomy

Type

Colostomy

Ileostomy

Cecostomy

Ostomy Appliance Changed

Ostomy Site Description


13/17

LAB TEST

New Lab Diagnostic

Diagnostic Date and Time

Department

Type Result Name Result Flag Reference Ranges

Complete Blood

Count w/o

Differential

WBC (10 x 3/uL) Normal/High/Low 4.0-9.0

RBC (mill/cumm) Normal/High/Low 3.90-4.98

Hemoglobin (gm/dL) Normal/High/Low 12.0-15.5

Hematocrit (%) Normal/High/Low 35-45

MCL (fL) Normal/High/Low 81-93

MCH (pg) Normal/High/Low 28-35

MCHC (gm/dL) Normal/High/Low 33-37

RDW (%) Normal/High/Low 11.4-15.2

Platelet Count

(1000/mm3)

Normal/High/Low 140-400

Mean Platelet Volume

(MPV) (fL)

Normal/High/Low 6.0-11.1

Complete Blood

Count

w/Differential

WBC (10 x 3/uL) Normal/High/Low 4.0-9.0

Diet Type


Regular Cardiac

Clear Liquids Full liquid diet

NPO Low cholesterol

Low Fat VegetarianLow Sodium Gluten-free

1800 cal ADA Low protein

Tube Feeds Vegan

Mechanical Soft Nectar thick

TPN Formula type

Pureed Diabetic Diet

Abdominal Girth

Cm

Measure at (check one)

Iliac CrestsUmbilicus

Site Marked


14/17

RBC (mill/cumm) Normal/High/Low 3.90-4.98

Hemoglobin (gm/dL) Normal/High/Low 12.0-15.5

Hematocrit (%) Normal/High/Low 35-45

MCL (fL) Normal/High/Low 81-93

MCH (pg) Normal/High/Low 28-35

MCHC (gm/dL) Normal/High/Low 33-37

RDW (%) Normal/High/Low 11.4-15.2

Platelet Count(1000/mm3)


Mean Platelet Volume

(MPV) (fL)


Neutrophils (%) Normal/High/Low 40-70

Lymphocytes (%) Normal/High/Low 10-20

Monocyte Count Normal/High/Low

Monocyte Percentage

(%)

Normal/High/Low 5

Open text field

(Immature Forms)

Normal/High/Low

Basic MetabolicPanel

Sodium (mEq/L) Normal/High/Low 135-145

Potassium (mEq/L) Normal/High/Low 3.5-5.1

Chloride (mEq/L) Normal/High/Low 98-107

CO2 (mEq/L) Normal/High/Low 22-29

Glucose (mg/dL) Normal/High/Low 70-99

Blood Urea Nitrogen

(mg/dL)


Creatinine (mg/dL) Normal/High/Low 0.50-1.00

Calcium (mg/dL) Normal/High/Low 8.4-10.5

Complete

Metabolic Panel

Sodium (mEq/L) Normal/High/Low 135-145

Potassium (mEq/L) Normal/High/Low 3.5-5.1

Chloride (mEq/L) Normal/High/Low 98-107

CO2 (mEq/L) Normal/High/Low 22-29

Glucose (mg/dL) Normal/High/Low 70-99

Blood Urea Nitrogen

(mg/dL)


Creatinine (mg/dL) Normal/High/Low 0.50-1.00

Calcium (mg/dL) Normal/High/Low 8.4-10.5

Total Protein (gm/dL) Normal/High/Low 6.4-8.4

Albumin (gm/dL) Normal/High/Low 3.5-5.2

Total Bilirubin (mg/dL) Normal/High/Low 0.0-1.2AST (U/L) Normal/High/Low 0-32

Alkaline Phosphate

(U/L)


ALT (U/L) Normal/High/Low 0-33

EGFR (ml/min/1.73m2) Normal/High/Low

Lipid Panel Total Cholesterol

(mg/dL)

Normal/High/Low Less than 200

Triglycerides (mg/dL) Normal/High/Low Less than 150

HDL Cholesterol

(mg/dL)

Normal/High/Low Greater than 40


15/17

LDL Cholesterol Normal/High/Low Less than 100

Prothrombin Time

(PT)

Prothrombin Time (sec) Normal/High/Low 11.5-15.0

INR Normal/High/Low 0.81-1.20

Partial

Thromboplastin

Time (PTT)

PTT (sec) Normal/High/Low 23.5-37.5-1.20

Hepatic Panel Albumin (grams/dl) Normal/High/Low 3.5-5.0Alkaline phosphatase,

sodium (IU/Liters)


ALT (SPGT) (IU/Liters) Normal/High/Low 24-36

AST (SGOT) (IU/Liters) Normal/High/Low 0-35

Bilirubin, direct

(mg/dL)


Bilirubin, total (mg/dL) Normal/High/Low 0.3-1.0

Protein, total, serum

(g/dL)


HbA1c Glycohemoglobin (%) Normal/High/Low 0.0-6.4

Other Normal/High/LowOther Normal/High/Low

Other Normal/High/Low






16/17

Tab: I/O

Intake

Oral Intake Date and Time

Oral Intake (mL)

Notes

Blood Products Date and

Time

Blood Products (mL)

Notes

Tube Feeding Date and

Time

Tube Feeding (mL)Notes

IVPB & IV Date and Time

IVPB & IV Push(mL)

Notes

Other Intake Fluid Date

and Time

Other Intake Fluids (mL)

Notes


17/17

Drains

Type Date and Time Value Notes

Chest Tube 1 mL

Chest Tube 2 mL

Drain 1 mL

Drain 2 mLDrain 3 mL

Drain 4 mL

Wound Vac 1 mL

Wound Vac 2 mL

GI


Emesis #

Emesis Volume mL

Tube, NG/OG/G mL

GI/Enternal


Tube Feeding mL

Diapers


Number of Diapers #

Diapers Weight kg

Stools Date and Time # mL Notes

Urine Date and Time # mL Notes

Output

Stools Date and Time

Stools (#)

Urine Date and Time

Urine (ml)

Documents

Clinical Assessment Form