Clinical Assessment Form

Tab: ADLs
ADL Assessment Date and Time

ADL Assessment
Check all that apply
Bed mobility
Transfer
Walking
Dressing
Eating
Toilet Use
Personal hygiene
Bathing

Subtab: GU
Urine Odor

Speech Assessment
Check all that apply
Rate 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
Frequency
Urgency
Oliguria
Polyuria
Anuria
Incontinence, Stress
Incontinence, Complete
Incontinence, Daytime
Incontinence, Nighttime
Hematuria








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

Subtab: Neuro
Orientation
Choose one Person, Time, Place, Situation Check all that apply Person
Disoriented Time
Place
Situation






Strength
Check where applicable LUE RUE LLE RLE
Moves Well Upon Request
Weak Movement Upon Request
Moves Well When Stimulated
Weak Movement When
Stimulated

No Movement
Behavioral/Emotional
Check one
Calm
Cooperative
Restless
Combative
Confused
Agitated
Untestable

Subtab: Mental Health


Behavior / Affect
Check all that apply
Appropriate
Agitated
Anxious
Depressed
Crying
Fearful
Hostile
Help-rejecting/complaining
Inappropriate
Embarrassed
Evasive
Resentful
Angry
Negativistic
Impulsive
Disturbed sleep
Nightmares
Night terrors
Regression
Other:
Stressors
Check all that apply
Condition
Hospitalization
Diagnosis
Procedure
Family Death
Family Illness
Family Problems
Finances
Surgery
Unknown Causes
Abuse/Neglect
Exposure to violence
Familial substance abuse
Developmental disabilities in caregivers
Impulsive acting out
History of DSS involvement
History of juvenile services involvement
Other:
Coping
Check all that apply
Well
Fair
Poor
Ineffective


Communication
Check all that apply
Verbal
Nonverbal
Blocking
Cimcumstantiality
Flight of ideas
Perseveration
Verbigeration
Neologism
Mutism
Acceptance


Thoughts exhibited
Check 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
Visual
Olfactory
Gustatory
Tactile
Depersonalization
Obsessive
Stereotyped
Consistent reactions
Inconsistent reactions



Reaction
Check all that apply
Over-reactive
Under-reactive
Purposeful
Disorganized
Stereotyped






Coping Style
Check all that apply
Acting out Passive aggression
Affiliation Projection
Altruism Protective identification
Anticipation Rationalization
Autisitic fantasy Reaction formation
Denial Repression
Devaluation Self-assertion
Displacement Self-observation
Dissociation Splitting
Humor idealization Sublimation
Intellectualization Supression
Isolation of affect Undoing
Omnipotence

Consistent reactions
Inconsistent reactions

Subtab: Musculoskeletal




















Subtab: Vascular Access

Level of orientation
Check all that apply
Confusion
Clouding of confusion
Stupor
Delirium
Acute brain syndrome
Dream state, coma
Memory disorders present
Muscle Tone / Strength: Check each column
All LUE RUE LLE RLE
Motor Strength Grade: Check all that apply
5 / 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
Check all that apply
Pain
Joint Swelling
Joint Stiffness
Contractures
Deformities
Crepitus
Weakness
Amputation
Fractures
Spasms
Weight Bearing / Gait
None
Check all that apply
Steady
Independent
Unsteady
Dependent
Asymmetrical
Jerky
Shuffling
Spastic
Developmentally
appropriate
Lordosis
Scoliosis
Kyphosis
N/A
Devices
Cast
Leg braces
Back brace
Boot
Sling
Cane
Crutches
Walker
Wheelchair
Chairfast
Bedfast
Prothesis
Other:
N/A
Assessment Date and Time
Location











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




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
Check all that apply
Aching
Burning
Throbbing
Piercing
Dull
Sore
Stabbing
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
Doppler
Capillary Refill
Check one per column
All LUE RUE LLE RLE
< 3 sec
> 3 sec
Absent
Edema
Check one per column
All LUE RUE LLE RLE
Absent
Trace
1+
2+
3+
4+
NonPitting
Pitting
Anasarca
Skin Color and Description











Subtab: Respiratory









Airway Device
Check all that apply
ETT Tracheostomy
Nasopharyngeal Mask Nasal Trumpet
Laryngeal Mask Oral Airway


Has Mechanical Device? If so, check one:
Check all that apply
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
Check all that apply
Pacer
IABP
CVP
Pulmonary Artery Monitoring
Cardiac Monitor
Arterial Line
Vasoactive Drips
Rate Of Drip
Methods
Chose one
Room Air %
Nasal Cannula L/min
Simple Face Mask %
Mist tent %
Trach Collar %
T-Piece %
Ambu Bag %
NRB mask %
CPAP %
BiPAP %
Blow-by %
Other (specify)

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 Ventilation
Rate
(breaths
per
minute:
Tidal Volume (Ml
per inspiration):
Positive End
Expiratory
Pressure:


Sputum
Check all that apply
Color Amount
Copious Yellow Serosanguinous
Bloody Purulent None
Serous Black Thin
White Brown Tenacious
Creamy Tan Moderate
Green Blood Tinged
Clear

Respiratory Symptoms
Check all that apply
Cough Hyperventilating Nasal Drainage
Shortness of Breath Decreased Smell Difficulty Breathing with
Activity Difficulty 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
Rales Inspiratory Stridor
Crackles Expiratory Anterior
Rhonchi Decreased Posterior
Wheeze Diminished


Right Middle Lobe, Check all that apply
Clear Coarse Absent
Rales Inspiratory Stridor
Crackles Expiratory Anterior
Rhonchi Decreased Posterior
Wheeze Diminished

Left Lower Lobe, Check all that apply
Clear Coarse Absent
Rales Inspiratory Stridor
Crackles Expiratory Anterior
Rhonchi Decreased Posterior
Wheeze Diminished

Right Lower Lobe, Check all that apply
Clear Coarse Absent
Rales Inspiratory Stridor
Crackles Expiratory Anterior
Rhonchi Decreased Posterior
Wheeze Diminished

Respirations: Select all that apply Grunting
Regular Labored Retracting
Irregular Gasping Nasal Flaring

Subtab: GI






GI Symptoms
Check all that apply
Anorexia
Belching
Vomiting
Heartburn
Nausea
Epi. Pain
Cramping
Constipation
Diarrhea
Abd. Pain
Flatulence
Hiccup
Incontinence
Early Satiety
Dysphagia
Encopresis
Bloody stools
Weight change
Abdominal Description
Check all that apply
All LUQ RUQ LLQ RLQ
Soft
Flat
Non Distended
Non Tender
Firm
Distended
Round
Rigid
Sunken
Tender
Guarding
Rebound
Scars
Hernia
Diet Tolerance
Check one
Excellent
Adequate
Inadequate
NPO
Other
N/A












Bowel Sounds
Check one per column
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















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
Check all that apply
Regular Cardiac
Clear Liquids Full liquid diet
NPO Low cholesterol
Low Fat Vegetarian
Low 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 Crests
Umbilicus
Site Marked

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
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 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)
Normal/High/Low 6-20
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)
Normal/High/Low 6-20
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 0.0-1.2
AST (U/L) Normal/High/Low 0-32
Alkaline Phosphate
(U/L)
Normal/High/Low 35-105
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

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 3.5-5.0
Alkaline phosphatase,
sodium (IU/Liters)
Normal/High/Low 30-120
ALT (SPGT) (IU/Liters) Normal/High/Low 24-36
AST (SGOT) (IU/Liters) Normal/High/Low 0-35
Bilirubin, direct
(mg/dL)
Normal/High/Low 0.1-0.3
Bilirubin, total (mg/dL) Normal/High/Low 0.3-1.0
Protein, total, serum
(g/dL)
Normal/High/Low 6.4-8.3
HbA1c Glycohemoglobin (%) Normal/High/Low 0.0-6.4
Other Normal/High/Low
Other Normal/High/Low
Other Normal/High/Low
Other Normal/High/Low
Other Normal/High/Low
Other Normal/High/Low
Other Normal/High/Low


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








Drains
Type Date and Time Value Notes
Chest Tube 1 mL
Chest Tube 2 mL
Drain 1 mL
Drain 2 mL
Drain 3 mL
Drain 4 mL
Wound Vac 1 mL
Wound Vac 2 mL

GI
Type Date and Time Value Notes
Emesis #
Emesis Volume mL
Tube, NG/OG/G mL

GI/Enternal
Type Date and Time Value Notes
Tube Feeding mL

Diapers
Type Date and Time Value Notes
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)