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Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

History of Present Illness including Admission Diagnosis &

Chief Complaint (normal & abnormal) supported with Evidence Based Citations

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations
Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),

include dates and rationales supported with Evidence Based Citations

Past Medical & Surgical History,

Pathophysiology of medical diagnoses

(include dates, if not found state so)

Supported with Evidence Based Citations

Erikson’s Developmental Stage with Rationale

And supported by Evidence Based Citations

Socioeconomic/Cultural/Spiritual Orientation

& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations

Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each

(“At Risk for…” nursing dx)

Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale

supported with Evidence Based Citations

Signs and


As evidenced by

Related to





Priority Nursing Diagnosis

(at least 2)

Written in three part statement



Measureable goal during your shift

(at least 1 per Nursing diagnosis)

Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching

(at least 4 per goal)

Rationale Each must be

supported with Evidence Based Citations


Goal Met, Partially Met,

or Not Met

& Explanation


Medications (with APA citations Class/Purpose Route Frequency Dose (& range)

If out of range, why?

Mechanism of action

Onset of action

Common side effects Nursing considerations

specific to this patient

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