MRN________________________ CSN____________________________

University of Central Florida – College of Nursing

Short Assessment Form
Student Name_________________________________________________________________________________

Instructor_____________________________________________________________________________________

Unit ________________________________________ Date_____________________________________________

Pt. Initials _______ RM_________ AGE________ GENDER____ ETHNICITY___________ Preferred LANGUAGE _____

Insurance________________________ Admit Date ___________ CODE STATUS ____________________________

ALLERGIES/reactions_____________________________________________________________________________

Primary Medical Diagnosis_______________________________________________________________________

History of Present Illness: (see H & P--please include a PQRST of the initial complaint as best as possible, then a chronological
timeline from the initial complaint to when the patient sought medical treatment, and what happened once treatment was given—
do not solely rely on the History and Physical Document, check Progress Notes too for up to date information): You can handwrite on
the back

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Past medical histories (include all)

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Prior Surgeries and hospitalizations________________________________________________________________

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Last hospitalization:

Date_________________________Reason___________________________________________________________

8/3/2022
Medication review (Include all dx w/ med, drug classification, dosage, route, frequency, reason this patient is on this medication and
other appropriate drug information); then, complete drug cards for clinical.

Current medications: (Prescribed and over the counter. Use back if needed).

Drug Name Diagnosis/Pharm class Why this patient is on Dose and Frequency
this medication? Route

Procedures/Treatments:

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CXR__________________________MRI_________________________OTHER______________________________

Therapy: PT OT SLP RT Restorative Frequency of therapy ordered______________

Dressing: Time (wound care orders) /materials (wound supplies used) Please see wound care treatment book

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Basic treatments (creams, turning, elevating, etc):

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General Appearance: Neuro (Including HEENT): Musculoskeletal:

Mood/Distress: Orientation: Mobility:
Grooming: Pupils: Strength:
Cooperative: Facial Symmetry: Deficits:
Tongue/Dentition: Assistive Devices:
Speech:

Cardiovascular: Respiratory: GI:

Rate/Rhythm: Sounds: Auscultation:
Heart sounds: Pattern: Contour:
Pulses: Oxygen Device/L/FiO2: Palpation:
Cap Refill:
Pulses: Intake:
UE: Doppler +1 +2 +3 Output:
LE: Doppler +1 +2 +3 Last BM:
Diet:
Nutrition: GU: Skin/Incision/Wound
Diet: Voids Incontinence Brief Bedpan
Accucheck: COCA:
Tubes/Drains
NGT Dobhoff PEG J-tube Feed Output: Foley
type:
Rate:
Suction:

IV Sites: Pain Management: Plan of Care:

8/3/2022
Social/Family History: include alcohol, drug, smoking use, including history of how much/how long, and living arrangements, family,
hobbies/occupation)

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LABS
WBC RBC Hgb Hct Plt

Na K Cl Mg BUN Crt

PT INR

CLIENT EDUCATION NEEDS – What does the nurse need to teach?

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DISCHARGE NEEDS – Prioritize If appropriate for patient

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OTHER COMMENTS – Anything important not mentioned otherwise

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8/3/2022
 Plan the day with your patient
(format any way that works for you while considering assessment and tasks that
should be or could be timed)

0800________________ 0900_______________ 1000 ________________ 1100 ______________

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1200________________ 1300________________ 1400_________________ 1500_____________

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1600_________________ 1700 ______________ 1800_________________ 1900 _____________

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VITAL SIGNS

Time________________ Time_______________ Time ________________ Time ______________

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8/3/2022