Anda di halaman 1dari 1

BISHOP STATE COMMUNITY COLLEGE

DEPARTMENT OF NURSING
CLINICAL PREPARATION TOOL
STUDENT:_______________________________________DATE:_________________CLINICAL WEEK_______________________________
SOURCE(S) of objective date w/ reliability rating (1 weak - 4 strong)_____________________________________________________________
Weekly Objective(s):______________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
CODE STATUS:_______________________________________
PATIENT HEALTH HISTORY
BIOGRAPHICAL DATA
Age/DOB:_______;_______/_______/________Sex:______Race:________Religion____________Marital Status_______# of Children________
Occupation:___________________Last Grade Completed:_________Language:_______________Usual Source of Healthcare:_____________
Reason for seeking healthcare:_____________________________________________________________________________________________
General appearance:______________________________________________________________________________________________________
HEALTH PERCEPTION/MANAGEMENT
Perception of health:______________________________________ Illness/Injuries__________________________________________________
________________________________________________________ _______________________________________________________________
________________________________________________________ _______________________________________________________________
Concerns about health:____________________________________ Hospitalizations/Surgeries:________________________________________
________________________________________________________ _______________________________________________________________
________________________________________________________ _______________________________________________________________
Measures to keep healthy:__________________________________ Drug/Tobacco/Alcohol Use:_______________________________________
________________________________________________________ _______________________________________________________________
Chronological Story:______________________________________ Medication History (What do they take at home?):____________________
________________________________________________________ _______________________________________________________________
________________________________________________________ _______________________________________________________________
________________________________________________________ _______________________________________________________________
Risk factors/Relevant History:______________________________ *Compliant w/ Meds @ home: Y N Explain;_________________________
________________________________________________________ _______________________________________________________________
Disability Assessment:_____________________________________ Immunization Status:_____________________________________________
________________________________________________________ *INDICATES POTENTIAL KNOWLEDGE DEFICIT
PAST HISTORY
Childhood Illnesses (if applicable):___________________________
________________________________________________________ ALLERGIES;____________________________________________________
________________________________________________________ ________________________________________________________________