Sin Nombre

____ Med/Surg ____ Acute ____ LT


____ Geri ____Acute ____LT


|Clinical Instructor _____________________ |Student: |
|Patient Assessment Tool . |Assignment Date:|
|( 2 |Facility/Unit: |
|Patient Initials: |Age: |Admission Date: |
|Gender:|Martial Status: |Medical Diagnosis: |
|Primary Language: | |
|Level of Education:|Medical/Surgical history: |
|Occupation if retired, previous occupation: | |
|Number/ages children/siblings: ||
| | |
| |Code Status: |
|Living Arrangements:| |
| |Surgery Date: Procedure: |
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|( 2 CC: In patient’s exact words |
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|( 3 HPI (History of Present Illness): “OLD CART” (Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatment) |
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