ADAPTED PSYCHIATRIC CLINICAL PREP TOOL IDENTIFYING DATA Date ____________________ Clinical Site: _________ Client Initials ____________ Age ____________________ Sex __________________ Race/Ethnicity ___________ Occupation ______________ Educational Level ______ Significant Other _________ Living Arrangements ______ Religion ______________ Allergies ________________ Diet ____________________ Medical Diagnosis _______________________________________ HEALTH HISTORY History of current illness leading to hospitalization. B. Past medical history. C. Family health trend history D. Medication history. E. Alcohol, tobacco, and drug history. F. Current (in hospital) medications. GENERAL DESCRIPTION Appearance Grooming _________________ Hygiene ___________________ Posture __________________ Hair color/texture ___________ Height/Weight ______________ Eye Contact ______________ Skin distinguishing marks (tattoos, scars, etc.) _______________________________________________ Does appearance fit the chronological age? ________________________________________________ Vital Signs Admit 1st day of care 2nd day of care T____ P____R____ BP___ Ht____ T____ P____R____ BP___ T____ P____R____ BP___ Wt____ Motor Activity: Tremors, tics, mannerisms, activity level, restless, agitated, aggressive, rigid, gait patterns, psychomotor retardation, range of movement Description: __________________________________________________________________________ ____________________________________________________________________________________ Speech Patterns: Slow or rapid speech, pressure of speech, volume, intonation, impairments, aphasia Description: __________________________________________________________________________ ____________________________________________________________________________________ General Attitude: Cooperative, friendly, hostile, defensive, uninterested, apathetic, attentive, guarded, suspicious Description: _________________________________________________________________________ ___________________________________________________________________________________ Emotions: Mood, sad, depressed, despairing, irritable, anxious, elated, euphoric, fearful, guilty, labile Description: _________________________________________________________________________ ___________________________________________________________________________________ Affect: Congruent, constricted, blunted, flat, appropriate Description: ________________________________________________________________________ __________________________________________________________________________________ THOUGHT PROCESSES Form of Thought: Flight of ideas, associative looseness, circumstantiality, tangentiality, neologisms, concrete thinking, clang, word salad, perseveration, echolalia, mutism, poverty of speech Description: _______________________________________________________________________ _________________________________________________________________________________ Ability to concentrate: ______________________________________________________________ Attention span: ____________________________________________________________________ Content of Thought: Delusions: Persecutory, grandiose, reference, control, somatic Description: ______________________________________________________________________ ________________________________________________________________________________ Suicidal/homicidal thoughts _____________________ Obsessions ______________________ Paranoia ____________________________________ Magical Thinking _________________ Religiosity __________________________________ Phobias _________________________ Perceptual Disturbances: Hallucinations: auditory, visual, tactile, olfactory, gustatory Description: ______________________________________________________________________ ________________________________________________________________________________ Delusions _______________________________________________________________________ Depersonalization _________________________ Derealization __________________________ Sensorium/Cognitive Ability Level of alertness/consciousness _____________________________________________________ Orientation to Time, Place, Person, Circumstance ________________________________________ Memory: Remote, recent, confabulations Description: ______________________________________________________________________ Capacity of abstract thought _________________________________________________________ Impulse Control: able to control impulses related to: hostility, fear, built, affection, sexual feelings Description: ______________________________________________________________________ Judgment and Insight: Ability to solve problems, make decisions, aware of limits, consequences of actions, awareness of illness. Adaptive/maladaptive use of coping strategies and ego defense mechanisms Description: ______________________________________________________________________ Medication Names Dose Frequency __________________________ _________________ ______________________ __________________________ _________________ ______________________ __________________________ _________________ ______________________ Lab Data: _________________________________________________________________________ __________________________________________________________________________________ Therapies: ________________________________________________________________________ __________________________________________________________________________________ ASSESSMENT CONCLUSIONS Nursing Diagnoses: Collaborative Problems: Discharge Planning Concerns