PATIENT ASSESSMENT

PATIENT ASSESSMENT CHECK-OFF

Student:  __________________________________ Date:_________________

Clinical Site:  __________________

OBJECTIVE:

To measure a patient’s vital sign of temperature, pulse, respiration and blood pressure.

To properly document any necessary information obtained through clinical assessment.

1.) Patient’s Medical Record #:  ________________________   

A.      Vital Signs:

       Blood Pressure:  _______               Temperature:  _______

       Respiration:  _______                  

       Respiration Characteristics:___________________________

       Pulse:  _______                          

       Pulse Characteristics: ________________________________

B.   Describe the patient’s general physical status including but not limited to patient’s appearance, mental status and level of consciousness:

C.   Document a short patient history:

D.   Document the reason for today’s clinical visit:

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