PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Student Name:

Week: 4

Dates of Care: 2/4/2022

Demographics and Brief History

Patient Initials

M D

Sex

F

Age

13

Room

281

Admitting Date

2/12022

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Depression. Suicidal ideation without a plan

Attending physician/Treatment team:

Precautions:

Suicidal precaution

Primary Diagnosis:

Major depressive disorder, recurrent, severe without psychotic symptoms. Anxiety disorder unspecified F 41.9

Co-morbidities:

Suicidal ideation, depression, and anxiety

Allergies:

No known allergies

Code Status:

Full Code

Isolation: (type and reason)

There is no isolation

Admission Height:

60.98 in

Admission Weight:

40.801 kg (89.0 lbs.)

Arm Band Location (colors & reasons)

No arm-band

Past Medical History: (pertinent & how managed)

Significant Events during this hospitalization but not during this clinical time: (examples include restrictive interventions or any medical emergencies. Include date, event and outcome)

Physical Assessments and Interventions: (Include all pertinent data)

Vital signs:

Time

T

98.7

97

P

90

95

R

16

18

B/P

125/89

115/63

General Appearance

· Grooming/Clothing

·

· Hygiene

·

· Posture

·

· Gait

·

· Obese/average or normal/ underweight

·

· Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings

·

Activities of Daily Living

· Sleep/rest

·

· Diet

· Regular

· Eat 76% of her food

· Exercise/mobility

·

· Elimination

·

· Hygiene

·

GI

Diet:

Blood Glucose (time & date):

Last bowel movement (time & date):

Pertinent Labs/Test:

Assessments: