Uploaded by Kristen Emery

adapted clinical assessment tool

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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
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