In: Nursing
rasmussen college clinical work sheet
Collect the entire history and do the Pre clinical, clinical,and post clinical assessment
The clinical worksheet should include complete history of the patient
Name........
Date:...... Student Name........ Clinical Site Instructor:.....
Previous Shift Report:......
Client age: .... Gender:.... Height:......Weight......... BMI......
Baseline vitals......BP...Pulse.........Respiration.....Temp......Pain score....... Transfer status......
Allerg status :.............Code Status........ Occupation.......
Religion......Pastoral care..........
Marital status.....Cultural background.........Primary language.......
Diet/Nutrition......Activity...........Fall risk......
Use of Alcohol(type ,frequency,amount).....Tobacco (Pack year):.......
Treatments:...........IV?Tubes/Ostomies....
Interdisciplinary cares:.......
Dressing/Wound(type and location)..........
Oxygen(delivary method & amount)......
Lab results.........
Diagnostic tests:.......