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

Symptoms

As evidenced by

Related to

Contributing

Factors

Diagnostic

Label

Priority Nursing Diagnosis *(at least 2)* *Written in three part statement*	Planning (outcome/goal) 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	Evaluation Goal Met, Partially Met, or Not Met & Explanation

MEDICATION LIST

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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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

Our Service Charter

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