Clinical Assessment
To err is human—but at what cost? People see doctors as healing angels and hospitals as relief havens. However, there have been enumerable cases of patients dying because of fatal mistakes and misinformed decisions of their healthcare attendees. Hospital visits aren’t supposed to be a Russian roulette where a patient goes home alive or not. One can only get lucky for so long. Patients and medical personnel will benefit from referring to clinical assessment tools before making decisions.
7+ Clinical Assessment Templates
A 2016 study by John Hopkins attributes about 10 percent of the United State’s mortality rate to medical error, placing it the third leading cause of deaths. Medical errors generally stem from miscommunication between the attending medical personnel as well as with the patients. Your patients’ lives are not the medium in exchange for the failure to keep accurate and readily-available records of patient assessment information. Good record-keeping isn’t just an organization feat; it can also help save lives. Take advantage of the following clinical assessment templates that will help you note the information that will affect decisions on prescription and treatments.
1. Clinical Assessment Form
Although there are standard operational procedures, medical attention is not a case of one-size-fits-all. A clinical assessment form contains information that are vital to the diagnosis and treatment decisions. It includes the patient’s medical history, examination results, and the doctor’s interpretation of the findings. By looking into the record, the physician can determine if the patient suffers from hypo- or hyperthyroidism. Both diseases affect the thyroid gland, but the former results from the lack of sufficient hormones. The latter is from too much hormone production. Download this assessment form now!
2. Medical Information Sheet
Assessing the health history of a person can paint a picture of an underlying, undiagnosed condition. It could be that for a long time, you have been prescribing medication for the symptoms that they have been complaining about. After several consultations, you gain more information from the patient, and you notice that the signs point to a particular health condition. This is true for illnesses like fibromyalgia and lyme disease. The sooner it is recognized, the easier the treatment and recovery will be. Spot the early signs of diseases with this Medical Information Sheet!
3. Patient Information Form
Medical personnel can refer to the patient’s information sheet to know his or her health status and what the patient needs. The record also allows for tracking of the person’s health over time. The form serves as the basis for advice or creating a treatment plan. This template lets you list the conditions that your patient suffered in the past. If he or she frequently suffers from seizures or losing consciousness, you would know that it’s something to look into as it could be a symptom for a serious health condition. Get your diagnosis right with this Patient Information Template!
4. Medication History Form
Before a physician can prescribe treatment, he or she should look into the medical history and medication sheet of the patient. For instance, people have been looking into laser-assisted in situ keratomileusis (LASIK) to correct their vision. According to an American Family Physician article, if the patient suffers from an autoimmune disease, recovery from LASIK might take be harder and longer. Also, if he or she had a history of herpes, the laser might reactivate the virus. As someone responsible for the well-being of another person, informed decisions are a prerequisite for recommending treatments or performing operations. Get this medical history sample now!
5. Free Nursing Assessment Form
A lot can happen between getting the drug from the pharmacy to having the patient taking the pill. Sometimes, it’s the wrong patient. A journal article pointed to patient misidentification as one of the causes for medication errors. Nurses are responsible for distributing medication for the patients as deemed necessary by the attending physicians. Therefore, nurses should have proper information about the prescription and the patient that needs the treatment. Provide your nurses with this editable assessment form that they can carry when they’re on rounds to help ensure that person A gets his needed medicine!
6. Free Psychological Assessment Form
Paris gave birth to the Binet’s test in 1905. It was a psychological examination for the intellectual and emotional wellness of kids in school. It was adapted into the United States’ pre-World War 1 educational system. During the Allied vs. Axis Powers conflict, the test was used to screen for soldiers who were fit for battle. Even after the wars, Binet’s test sired more psychological test derivatives that are still used today.
Psychological assessment is collecting relevant information for psychological evaluation. Questionnaires, interviews, and behavioral observations can be used to come to a decision. The conclusion of the assessment will answer the referral question, which is the reason as to why the test is performed. Before the test can proceed, the assessor must first get to know the patient. It will help the evaluator select what approach he or she will use on the patient to arrive at conclusive results. Get to know your patients with this downloadable psychological assessment template!
7. Psychological Test Referral Form Sample
Before an assessor evaluates a patient, there has to be a referral for testing. The reference can be external, meaning outside of the practice. It can also be internal, where the recommendation came from other mental health professionals. The referral form contains the intention of the evaluation. It informs the evaluator of what the source wants to know. We provided you a copy of the referral form when you will refer a person to a health professional for an assessment. The downloadable file includes initial psychological assessment reports for children and adults, a list of psychological tests, instruction form, and test request forms.
8. Patient Assessment Guide
During a medical emergency, there will be times that the patient is responsive and is without life-threatening injuries. You can ask them how and when their illness started. You should also evaluate the symptoms that they’re complaining about. Get information about their current medication from them or their medical records. You should also inquire about how the medical emergency started. You can’t risk forgetting a vital detail because that might have irreversible consequences. Download this sample checklist of what needs to be assessed. It includes a guide on other emergency responses that you might need to administer.
Share :
