University of Santo Tomas College of Nursing

PATIENTCARE RECORD Patients Name: Chief Complaint: Room No: Diagnosis: Ward: Surg: Date:

A. HEALTH HISTORY I. Biographical Data: Age: Birthdate: Address: Sex: Citizenship: Civil Status: Religion: Educ. Attainment:

II. History of Present Illness

III. Past Health History

Medication Allergies

IV. Family Health History

University of Santo Tomas College of Nursing Patient Care Record B. REVIEW OF SYSTEMS PATIENTS NAME: CHIEF COMPLAINT:
VITAL SIGNS oral rectal axilla RR = BP = PSYCHOSOCIAL

RM NO: DIAGNOSIS:

DATE:

Temp = PR =

Calm Anxious Cooperates with care OTHER NEURO W ithin normal level W NL except for: Level of Consciousness GCS: Orientation Memory Deficit Sensory Deficit Aids hearing vision Cranial nerve deficit Language deficit OTHER CARDIOVASCULAR W ithin normal level W NL except for: Irregular heart rate murmur Edema (location) Coolness (location) Color (location) Sensation (location) Pulses (location) Mucous membranes IV lines OTHER RESPIRATORY W NL except for: dyspnea nasal flaring diminished crackles

GENITOURINARY W ithin normal level W NL except for: burning urgency dysuria hesitancy urinary incontinence anuric polyuria nocturia catheter drainage tubes Urine: color amount cloudy sediment heme Genitalia: discharge OTHER MUSCOLOSKELETAL W ithin normal level W NL except for: limitation of movement (location) balance gait ROM assistive device joint swelling muscle weakness muscle tone flaccid Activity level: OOB partial assistance complete assistance OTHER INTEGUMENTARY W ithin normal level W NL except for: ecchymosis lesions erythema rashes pressure ulcer/grade/location pressure relief device incision (location) drains turgor OTHER

bruises

secretions

W ithin normal level Irregular heart beat shortness of breath cough Breath sounds: unequal coarse/rhonchi artificial airway OTHER

wheezes

COMFORT W ithin normal level W NL except for: pain location pain characteristics receiving: narcotics other analgesics HYGIENE shower bath mouthcare pericare antiembolic hose OTHER PRECAUTIONS falls aspiration neutropenia suicide airborne seizure radiation OTHER

GASTROINTESTINAL W ithin normal level W NL except for: NPO Diet TPN extraoral feeding Nausea Vomiting dysphagia gas eructation regurgitation Abdomen: firm tender distended Bowel sounds: hyperactive hypoactive absent Stool: no flatus fecal incontinence constipation diarrhea Stoma OTHER

Name and Signature:

University of Santo Tomas College of Nursing Patient Care Record C. SUMMARY OF DIAGNOSTIC PROCEDURES DATE PROCEDURE SIGNIFICANT FINDINGS INFERENCE

University of Santo Tomas College of Nursing Patient Care Record E. NARRATIVE OF NURSING PROBLEMS, INTERVENTIONS AND OUTCOMES OF CARE DATE/ TIME REMARKS

University of Santo Tomas College of Nursing Patient Care Record F. TEACHING AND DISCHARGE PLAN TEACHING PLAN: Content Areas Objective Strategy of Implementation Evaluation

DISCHARGE PLAN: Goal

Strategy of Implementation

Evaluation