Get Chipola College Database And Physical Assessment Tool 2020-2025

Filling out the Chipola College Database And Physical Assessment Tool is an essential task for accurately documenting client assessments. This guide provides clear, step-by-step instructions to assist you in effectively completing the form online.

Follow the steps to accurately complete the Database And Physical Assessment Tool online.

1. Select the ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering the student’s name in the designated field labeled 'Student Name.'
3. Input the date in the corresponding field. Make sure the format is consistent.
4. For the DATABASE and PHYSICAL ASSESSMENT TOOL section, enter the client's initials, room number, admission date, and any allergies in the provided fields.
5. Document the medical diagnosis and chief complaint in their respective areas, ensuring clarity and detail.
6. Provide a thorough history of the present illness, past medical history, and past surgical history by filling in the appropriate sections.
7. Record family history and substance use including alcohol, tobacco, and recreational drugs.
8. In the neurologic section, classify the patient's level of consciousness and orientation, and note the pupil size and speech clarity.
9. Complete the vital signs section, including blood pressure, temperature, pulse, respiratory rate, and pain level.
10. Fill out the integument, head and neck, thorax/lungs/heart, abdomen, peripheral vascular, genitourinary, musculoskeletal, and IV site sections, paying attention to detail and specificity.
11. List any noted problems and associated systems, as well as prioritize six nursing diagnoses.
12. Include reference ranges for lab values where applicable.
13. Finally, save your changes, download, print, or share the completed form as necessary.

Complete the Database And Physical Assessment Tool online today for accurate documentation.