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Nurse Process Recording

CLIENT’S NAME: ______________________________ STUDENT’S NAME: ______________________________

DATE AND TIME OF INTERACTION: ______________________________

CLIENT’S BACKGROUND INFORMATION: AGE ______ SEX ______ RELIGION __________


CULTURAL/ETHNIC FACTORS: ______________________________

PRSENTING PROBLEMS: __________________________________________________________________________________________


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TENTATIVE DIAGNOSIS: __________________________________________________________________________________________


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PHYSICAL STATUS: __________________________________________________________________________________________


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ENVIRONMENTAL SETTING: ____________________________________________________________


GOALS: ____________________________________________________________

NURSE/CLIENT INTERACTION:
NURSE CLIENT INTERPRETATION
(include thoughts and feelings) (include non-verbal observation) (include techniques used and whether effective)
NURSE CLIENT INTERPRETATION
(include thoughts and feelings) (include non-verbal observation) (include techniques used and whether effective)
NURSE CLIENT INTERPRETATION
(include thoughts and feelings) (include non-verbal observation) (include techniques used and whether effective)

SUMMARY STATEMENT: __________________________________________________________________________________________

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REFERENCES/RESOURCES:
__________________________________________________________________________________________

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