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PATIENT ASSESSMENT EXERCISE

STEP 1For this exercise, select a patient who is receiving respiratory care

NOTE: The medical record review and the physical assessment must be from the same patient

STEP 2Review the patient’s medical record and record the information requested in the Medical Record Review section of this exercise

STEP 3Perform and physical assessment.  Record your findings in the Physical Assessment section of this exercise

STEP 4Submit your completed patient assessment to the Director of Clinical Education on the designated date

MEDICAL RECORD REVIEWStudent Name: ____________________________ Date: _______

Gender:

Age:

Admitting Diagnosis:

History & Physical:

Surgical Procedures:

Consultations / MD Progress Notes:

Respiratory Care / Nursing Notes:

Respiratory Care Orders:

Current Medication (Respiratory/Nonrespiratory):

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