PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
Student Name: Week: Dates of Care:
Patient Initials Sex Age Room Admitting Date Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?
Attending physician/Treatment team: Consults:
Present Diagnosis: (Why patient is currently in the hospital) ER Management: (if applicable)
Allergies: Code Status: Isolation: (type and reason)
Admission Height: Admission Weight: Arm Band Location (colors & reasons)
Communication needs: (verbal, nonverbal, barriers, languages)
Past Medical History: (pertinent & how managed)
Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)
Tests/Treatments/Interventions impacting clinical day’s care (include current orders)
Assessments and interventions: (Include all pertinent data)
Vital signs: (2 sets per day)
Time
T
P
R
B/P
Time
T
P
R
B/P GI:
Diet:
Swallow precautions:
Tube feedings:
NG / G tube:
Blood Glucose: (time & date)
Last bowel movement: (time & date)
Pertinent Labs/Test:
Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)
Respiratory:
02 modalities:
02 Saturation:
Suction:
Resp Rx’s:
Trach:
Chest Tubes:
Pertinent Labs/Test:
Assessments/Interventions: (Lung sounds, cough, sputum, SOB) Neurosensory:
Neuro checks:
Alert & Orientated:
Follows commands:
Speech Comprehensible:
Pertinent Labs/Test:
Assessments/Interventions:
(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)
Cardiovascular:
Telemetry:
Pacemaker/IAD:
DVT Prevention:
Daily Weights:
Pertinent Labs/Test:
Assessments/Interventions:
(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations) Musculoskeletal:
Activity:
Traction:
Casts/Slings:
Pertinent Labs/Test:
Assessments/Interventions:
(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps
Renal:
Catheter (indwelling/external):
CBI:
Dialysis:
A/V access:
Pertinent Labs/Test:
Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O) Skin:
Braden Score:
Pertinent Labs/Test:
Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)
Pain:
Pain score:
Assessments/Interventions:
(scale used, location, duration, intensity, character, exacerbation, relief, interventions) Vascular Access: (IV site)
Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)
Gyn:
Gravida/Para:
LMP:
Last Pap:
Breast exam:
Pertinent Labs/Test
Assessment/Interventions: (bleeding, discharge) Post-operative /procedural:
Assessments/Interventions:
(immediate post procedure care)
Safety:
Call light:
Bed Rails:
Bed alarms:
Fall risk:
Assistive Devices:
Sitter use:
Restraints (type, duration & reason):
Assessment/Interventions (modifications to room, environment, Patient) Advance Directives/Ethical considerations:
DPOA:
Hospice:
Pertinent Data (Labs, X-rays, Etc.)