Patient Clinical Assessment Form
Document what you found, not what you expected — a structured first assessment that makes the invisible visible and the baseline retrievable
What it is
A structured initial clinical assessment form for hospital admission. Covers presenting complaint, history, allergies, medications, examination findings, and initial clinical impression. Designed for completion by the admitting doctor or nurse practitioner within four hours of admission. The most critical field — allergies — is at the top in a separate coloured box so it cannot be missed. An assessment not documented is an assessment that did not happen for clinical, legal, and accreditation purposes.
ASF criterion
Evidence for: Hospital Standard 4, criterion 4.8 (Non-Negotiable) — Every Patient Gets a Real Assessment.
| PATIENT CLINICAL ASSESSMENT · ASF-TOOL-CAP-02 · Date: Time: | |||
|---|---|---|---|
| Patient name | DOB | ||
| ID number | Ward / bed | ||
| ⚠ ALLERGIES — complete first, before any other section: | |||
| Drug / substance: Reaction: ☐ NKDA | |||
| Presenting complaint & history | |||
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| Vital signs on admission | |||
| BP (mmHg) | Heart rate | ||
| Respiratory rate | Temperature (°C) | ||
| SpO2 (%) | GCS / Consciousness | ||
| Current medications (list all — include dose and frequency) | |||
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| Clinical examination findings | |||
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| Initial clinical impression & plan | |||
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| Assessing clinician name & role | |||
| Signature | Time completed | ||
ASF-TOOL-CAP-02 · Toolkit 33 — Clinical Assessment & Care Planning · france-asf.fr/tools · ASF original © Accréditation Sans Frontières · CC BY-NC-SA 4.0 · Keep this line on all adapted versions
