C.S. MOTT COMMUNITY COLLEGE
SCHOOL OF HEALTH SCIENCES
CLINICAL ASSESSMENT FORM: SECOND YEAR
Instructions:
1. Include as much information about the client as possible, based on subjective data (interview
with client) and objective data (from Kardex, chart, care plan, and physical assessment of client).
2. Treat this like an ADMISSION ASSESSMENT.
3. It is permissible to use a potential problem (At Risk for…) for the NANDA diagnoses or to
state NO diagnosis (if no problem is identified in a section).
4. Describe what you see, hear, feel, and smell as you do your assessment, using descriptive terminology.
5. All meds on the client's orders/clinical focus should be on this assessment somewhere. For each
medication, give dose and frequency.
6. Do not leave any of the spaces blank, but indicate the reason you are unable to assess (i.e. Info.
not available (INA) = information pertains to this client, but is not available or NA = information is not
pplicable to this client). a
7. HIGHLIGHT WITH COLORED MARKER ABNORMAL FINDINGS THRU OUT THIS FORM.
8. Keep all assessments and care plans for your own future reference and have available upon request for
future instructors.
9. The term RANGE refers to the previous 24 hour values for this client.
10. ALL information obtained on this form MUST be kept confidential.
Client's Initials______ Age______ Gender ______ Student Name
Client's Room Number_______ Date of Assessment
Admitting Diagnoses & Date
Current Surgical Procedures & Dates
Prior Health History within past 5 years (surgeries, injuries & medical conditions)
Medications Prior to Admission (including prescriptions, OTC, and herbal medications)
Family History (specify conditions and relationship to client)
Allergies (list & state reactions):
Drug:
Food:
Environmental:
Latex:
Other Allergies impacting clients care at this time:
Code Status/Advanced Directives
Current Adult Immunizations (i.e. pneumococcal, influenza, DT, hepatitis, MMR, Meningococcal):
