Student name: Instructor :

1. Student name: Instructor: History of Present Illness: (A brief statement by the Doctor explaining what happened to the patient before they got to the hospital) Erikson’s Developmental Stage Related to Pt & APA citations • Patient Education / Discharge Planning: • (Barriers to education, learning goals, learning outcomes) (Home Vs Facility, services needed after discharge, adaptive equipment needed for home.) Cultural Considerations: Ethnicity, Occupation, Religion, Family Support, Financial Considerations. Pathophysiology of Admitting Dx with APA references: Diagnostic Tests / Lab Result w/ Dates and Normal Ranges Chief Complaint Patient Information Name: Age: Gender: DPOA: Living Will: Ht: Wt: BMI: • Previous Medical History: Admitting/Current Diagnoses(es): • Plan of Care: Previous Surgical History:

2. Objective Signs Priority Nursing Diagnosis #1 Vital Signs Priority Nursing Diagnosis #2 Neurological Cardiovascular Respiratory Nutrition / Hydration GI Rest / Exercise GU Outcome / Goal #2 Outcome Goal #1 (specific, measurable, achievable, realistic, time bound) Psychosocial Musculoskeletal Endocrine Integumentary Interventions #2 Evaluation #2 Interventions #1 Evaluation #1 (start with “goal met” or “goal not met”) “Risk For” Evaluation • “Risk For” Interventions “Risk for” Diagnosis “Risk For” goal

3. Davis, 2015.

4. References