Sample clinical assessment report

I asked if she was taking her medication like the doctor had prescribed. Maybe this is one of the reasons he had to have his CABG surgery that was necessitated by the coronary artery disease. Both patients had stable vital signs and no critical problems, so atthe second patient actually requested to be discharged.

The first patient had meds due at and the second patient was getting morphine via IV hourly so he was going to be buzzing around The patient reported being more comfortable.

With two patients, it is important to get the newest RN patient reports and then prioritize patient care in order of critical urgency. She is a fireball. Over time, persistent high blood sugar levels may damage blood vessels and in the body, increasing your risk of eye, heart, blood vessel, nerve, and kidney disease.

You go into the computer and select the discharge summary and print it out. It was important to have up to the minute information available as the doctor needed to be updated regularly. She said that she was being a good girl and taking the medication like she was supposed to do.

Clinical Forms

He had a history of atrial fibrillation, coronary artery disease, hypertension, hyperlipidemia, Type II diabetes, renal insufficiency and a high PSA.

We discussed his dietary options, which were diabetic and heart healthy. The only thing I had to do was give a Fleet enema, reinforce teaching about diet, medications and ambulation and do multiple assessments. The second patient was in a great deal of pain and had different needs, so I had to be sure I knew exactly what was happening and if his needs were more urgent than the other patient.

You run through it with them, answer any questions and then they leave. I asked if she was feeling better. When I reassessed his abdomen it was semi-firm and his bowel sounds were still hypoactive, but more active than earlier.

My patient was a 73 year-old male that had just undergone a facet injection for lower back pain and left-sided sciatica.

But, I am glad the patient education is paying off. I first printed out the RN patient reports to see if anything had changed for the original patient, because I had an idea of what he already required.

After that patient left, I then did my assessment on my other patient and he was stable without any change from the day before.

It had been four days since his last bowel movement. I performed my assessment and noticed that he had a hard, distended abdomen and hypoactive bowel sounds. She said she was feeling better five minutes after it the TIA happened. Several things I had to focus on were proper medication administration, proper charting and patient comfort level.

Since I had two patients today, I had to do some prioritizing before I could do anything else. Importance or influence for you: So, we went in and gave him his 2mg morphine via IV. It is important to understand the pathophysiology of diseases. Then, Gina RN and I went over the discharge paperwork with the patient and his wife.

There are no signatures required. The discharge process is pretty simple. You should also go to the Micromedex and print out information on any prescriptions they will be filling.

The multiple medications and multiple patients made that more challenging, but nonetheless important to check each time a medication was delivered.

I had a lot of charting to do. It helps in patient teaching and it also helps you understand how it can lead to other disease processes. I was assigned the same patient and the patient next door, a year-old male who had a repair for a meningiocele after laminectomy.

I would like to perform a bladder scan and a Foley cath if possible.Full Psychological 1.

SAMPLEConfidential Psychological Report Names have been changed For Professional Use Only Prepared By: Debra Bassett EdS Student in School Psychology University of Northern Colorado June 28, Downloadable Templates and Tools for Clinical Research. Clinical study report template: Finances Management: Budget Monitoring tool: Informed Consent Sample only in household community: Providing clinical care: Concomitant medication log.

Managing biological samples SOP.

Report Examples & Samples

This treatment discharge summary is a sample work product of the Professional a treatment program, rather than try to address the clinical issues identified in his assessment in a weekly outpatient psychotherapy process. Such an outpatient treatment, ASSESSMENT REPORT EXAMPLE.

Downloadable Templates and Tools for Clinical Research

Home ⁄ Student Nurse Resources ⁄ Clinical ⁄ Charting ⁄ Sample Clinical Reflection. Sample Clinical Reflection Type II diabetes, renal insufficiency and a high PSA.

I performed my assessment and noticed that he had a hard, distended abdomen and hypoactive bowel sounds.

up to date and relevant, Student Nurse Journey cannot take. The Aims of Report Writing for the First Clinical Interview According to Cansever (), the aim of the psychological assessment report is to present the patient’s personality and to recommend the ways that will help the patient to solve his/her problems.


Clinical Assessment Canada

Testing Hypotheses of Clinical Assessments Words | 3 Pages. Testing Hypotheses of Clinical Assessments "The initial assessment sessions are crucial in the practice, research, and theory of cognitive and behavioral psychotherapy," and as such it is incredibly important (Sanavio,p ).

Sample clinical assessment report
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