Name of Institution Assigned: _____________________________________________________

Area of assignment : ___________________________ Date of Assignment : ______________

Concept : ______________________________________________________________________
Name of Clinical Instructor : __________________________________ Rotation Grade : _______

General Objectives

After (number of days of exposure) exposure at ____(institution)____, being aided with the concept
of,_________________________________________________________________________ I will be able to gain exact
knowledge, enhance my skills, and develop a positive attitude towards the care of the clients.

Specific Objectives
After two weeks exposure at ____(institution)____, I will :
1. be oriented to the physical setup, rules and policies and the staff.
2. exhibit professionalism in the performance of all functions in the clinical area.
3. display respect during all interaction with the client and towards the staff nurses, clinical instructor and fellow students.
4. establish rapport with the client. (minimum of 10 )

History
Biographic Data:
Name: ________________________________
Occupation: _________________________
Gender: _______________________________
Nationality: _________________________
Birth Date: _____________________________
Birth Place: _____________________________ Religion: ____________________________
Age: ___________________________________ Source of Data: ______________________
Address: ________________________________ Date & Time of Admission: _____________
Educational Level : ________________________
Attending Physician: ___________________
Marital Status: ___________________________
Diagnosis: ___________________________

Chief Complaint: (patient’s exact words)

___________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

1
Current Health Status (History of Present Illness):
Character: (How does it feel, look, smell, sound, etc.?)
___________________________________________________________________________
_________________________________________________________________________________
Onset: (When did it begin; is it better, worse or the same since it began?)
___________________________________________________________________________
_________________________________________________________________________________
Location: (Where is it? Does is radiate?)
___________________________________________________________________________
_________________________________________________________________________________
Duration: (How long it lasts? Does it recur?)
___________________________________________________________________________
_________________________________________________________________________________
Severity: (How bad is it on a scale of 1 to 10?)
___________________________________________________________________________
_________________________________________________________________________________
Pattern: (What makes it better? What makes it worse?)
___________________________________________________________________________
_________________________________________________________________________________
Associated factors: (What other symptoms do you have with it? Will you be able to continue doing your work or
other activities [leisure or exercise]?)
___________________________________________________________________________
_________________________________________________________________________________

Past Health History:

Previous Hospitalization: (when? what reason? management?)
___________________________________________________________________________
_________________________________________________________________________________
Birth Problems:
___________________________________________________________________________
_________________________________________________________________________________
Childhood Illnesses: (acute & chronic)
___________________________________________________________________________
_________________________________________________________________________________
Immunizations: (dates & reactions)
___________________________________________________________________________
_________________________________________________________________________________
Adult Illnesses: (acute & chronic)
___________________________________________________________________________
_________________________________________________________________________________
Surgeries: (minor & major)
___________________________________________________________________________
_________________________________________________________________________________
Accidents:
___________________________________________________________________________
_________________________________________________________________________________
2
Pain:
___________________________________________________________________________
_________________________________________________________________________________
Allergies: (allergens [medication, food & environment] & reactions)
___________________________________________________________________________
_________________________________________________________________________________
Treatments: (reasons)
___________________________________________________________________________
_________________________________________________________________________________
Medications: (prescriptions, OTC, home remedies, herbal preparations, alternative therapies)
___________________________________________________________________________
_________________________________________________________________________________

Family Health History:

Grandparents, Parents, Aunts/Uncles & Siblings:
(age? living or deceased? deceased date? cause of death?
(illness? asthma, cancer, cataracts, diabetes, glaucoma, heart disease, haemophilia, hypertension, sickle cell anemia, stroke, renal
disease, tuberculosis, STD’s)
___________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Genogram:

Legend :
Patient X
Male
Heredofamilial diseases :

Female Hypertensive H

Deceased male * Use first letter of the disease

Deceased female

3
Psychosocial Health History (Lifestyle & Health Practices):
ADL: (typical day? am to pm)
___________________________________________________________________________
_________________________________________________________________________________

Diet: (24 hour food & fluid intake? amount? preparation?)

___________________________________________________________________________
_________________________________________________________________________________

Medication & Substances Use: (caffeine, nicotine, alcohol, illicit drugs)

___________________________________________________________________________
_________________________________________________________________________________
Elimination: (bowel, bladder, skin)
___________________________________________________________________________
_________________________________________________________________________________

Sleep & Rest: (quality & quantity? nap?)

___________________________________________________________________________
_________________________________________________________________________________

Exercise:
___________________________________________________________________________
_________________________________________________________________________________

Leisure : (hobbies, social activities)

___________________________________________________________________________
_________________________________________________________________________________

Religious Observations: (health beliefs, values)

___________________________________________________________________________
_________________________________________________________________________________

Environment: (home, neighborhood, & work)

___________________________________________________________________________
_________________________________________________________________________________

Stressors & Coping Strategies:

___________________________________________________________________________
_________________________________________________________________________________

Roles & Relationships: (family & society)

___________________________________________________________________________
_________________________________________________________________________________

Self-Concept:
4
 ___________________________________________________________________________
_________________________________________________________________________________

Self-Care Responsibilities: (health promoting activities? safe sex, basic hygiene practices, regular check-ups, BSE/TSE; accident prevention & hazard
prevention activities?)
___________________________________________________________________________
_________________________________________________________________________________

Developmental Level:

___________________________________________________________________________
_________________________________________________________________________________

Review of Systems (ROS)

General: (weight loss, weakness, feelings fatigue, mood changes, night sweats, or bleeding tendencies)
__________________________________________________________________________________
__________________________________________________________________________________
Skin, Hair, and Nails: (skin diseases, skin pigmentation, bruising, temperature, jaundice, ithching, excessive sweating or drying, rashes, change in
color or size of moles, lesions or sores that heal slow, balding, dandruff, clubbing and splitting of nails)

__________________________________________________________________________________

__________________________________________________________________________________
Head: (headache, fainting, dizziness, fall or accident resulting in unconsciousness, swelling, stiffness of neck, difficulty swallowing,

sore throat)

__________________________________________________________________________________

__________________________________________________________________________________
Eyes: (difficulty seeing, eye infection, redness, itching, excessive tearing, halos around lights, blurring, and loss of side vision, moving black spots
/specks in visual fields, flashing lights, double vision, sensitivity to light, eye pain, and glasses/contact lenses)
__________________________________________________________________________________

__________________________________________________________________________________

Ears: (loss of hearing, ringing or buzzing, earaches, itching, drainage from ears, dizziness, exposure to loud noises, hearing aids)
__________________________________________________________________________________

__________________________________________________________________________________

Nose: (frequent colds, nosebleeds, allergies, pain, tenderness, postnasal drip, rhinorrhea, nasal obstruction, sneezing)
__________________________________________________________________________________

__________________________________________________________________________________
5
Mouth, Throat, and Sinuses: (sore & bleeding gums, lumps or white spots, mouth lesions, dentures, toothaches, cavities, sore throats, difficulty
swallowing, hoarseness, and snoring)
__________________________________________________________________________________

__________________________________________________________________________________

Neck: (pain, swelling, stiffness, limited movement, swollen glands, enlarged lymph nodes)
__________________________________________________________________________________

__________________________________________________________________________________

Breasts and Regional Lymphatics: (lumps or discharge from nipples, scaling or cracks around nipples, dimpling or changes in breast size, swollen
or tender lymph nodes in axilla, BSE pattern, mammogram)
__________________________________________________________________________________

__________________________________________________________________________________

Thorax and Lungs: (difficulty breathing, wheezing, pain, shortness of breath during routine activity, orthopnea, cough or sputum, hemoptysis,
respiratory infections, X-ray)
__________________________________________________________________________________

__________________________________________________________________________________

Heart and Neck Vessels: (heart disease, last blood pressure, ECG tracing or findings, chest pain or pressure, palpitations, edema, heart murmur)
__________________________________________________________________________________

__________________________________________________________________________________

Peripheral Vascular: (swelling, or edema of legs and feet; pain; cramping; sores or ulcers on legs; color or texture changes on the legs or feet, varicose veins)
__________________________________________________________________________________

__________________________________________________________________________________

Gastrointestinal: (nausea, vomiting, loss of appetite, indigestion, heartburn, bowel habits, bright blood in stools, tarry-black stools, diarrhea,
constipation, pain with defecation, abdominal pain, excessive gas, hernias, hemorrhoids, rectal pain, colostomy, ileostomy)
__________________________________________________________________________________

__________________________________________________________________________________

Male Genitalia: (excessive or painful urination, frequency or difficulty starting and maintaining urinary stream, leaking of urine, blood noted in urine, sexual
problems, perineal lesions, penile drainage, pain or swelling in scrotum, difficulty achieving an erection and/or difficulty ejaculating, exposure to sexually transmitted
infections)
__________________________________________________________________________________

__________________________________________________________________________________

Female Genitalia: (sexual problems; sexually transmitted disease; voiding problems [dribbling, incontinence]; reproductive data such as age at menarche,
menstruation [length & regularity of cycle], pregnancies, and type of or problems with delivery, abortions, pelvic pain, birth control, menopause [date or year of last
menstrual period], and use of hormone replacement therapy)
__________________________________________________________________________________
6
__________________________________________________________________________________

Musculoskeletal: (swelling, redness, pain and weakness of muscles; stiffness, swelling and soreness of joints; leg cramps; bone defects; ability to perform activities
of daily living; muscle strength)
__________________________________________________________________________________

__________________________________________________________________________________
Neurologic: (general mood; emotional state changes; concussions; headache; difficulty walking; unconsciousness; seizures; tremors; paralysis; numbness; tingling
or burning sensations in any body part; weakness on one side of body; speech problems; loss of memory; disorientation; forgetfulness; unclear thinking; loss of
coordination; difficulty learning)
__________________________________________________________________________________

__________________________________________________________________________________
Endocrine: (history of goiter; heat or cold intolerance; diabetes; excessive thirst; excessive eating)
__________________________________________________________________________________

__________________________________________________________________________________

Gordon’s Functional Health Pattern

General Survey:
Body Measurements: Vital Signs:
Height: __________ Temperature: __________
Weight: __________ Pulse Rate: __________
Waist & Hip Circumference:__________ Respiratory Rate: __________
Midarm Circumference: __________ Blood Pressure: __________
Triceps skin fold thickness: __________ Pain Scale: __________
Ideal Body Weight: __________
Body Mass Index: __________

Do you have any allergies? No ___, Yes ___

What? __________________________________________________________________
(Check reactions to medications, foods, cosmetics, insect bites, etc.)

HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN

OBJECTIVE:
1. Mental Status
a. Oriented _____, Disoriented _____
Time: Yes _____, No _____; Places: Yes _____, No _____; Person: Yes _____, No _____
b. Sensorium
Alert _____, Drowsy _____, Lethargic _____, Stuporous _____, Comatose _____
Cooperative _____, Combative _____, Delusional _____
c. Memory
Recent: Yes _____, No _____; Remote: Yes _____, No _____
2. Vision
a. Visual Acuity
Both eyes: 20/_____, Right 20/_____, Left 20/_____, Not assessed _____
b. Pupil Size:
Right: Normal _____, Abnormal _____; Left: Normal _____, Abnormal _____
3. Hearing
a. Not assessed _____
b. Right ear: WNL _____, Impaired _____, Deaf _____
Left ear: WNL _____, Impaired _____, Deaf _____
c. Hearing Aid: Yes _____, No _____

7
 4. Taste
a. Sweet: Normal _____, Abnormal _____, Describe: ______________________________
_______________________________________________________________________
b. Sour: Normal _____, Abnormal _____, Describe: _______________________________
c. Tongue Movement: Normal _____, Abnormal _____, Describe: ____________________
________________________________________________________________________
d. Tongue Appearance: Normal _____, Abnormal _____, Describe: ____________________

5. Touch
a. Blunt: Normal _____, Abnormal _____, Describe: ______________________________
______________________________________________________________________
b. Sharp: Normal _____, Abnormal _____, Describe: ______________________________
______________________________________________________________________
c. Light Touch: Normal _____, Abnormal _____, Describe: _________________________
______________________________________________________________________
d. Proprioception: Normal _____, Abnormal _____, Describe: _______________________
e. Heat: Normal _____, Abnormal _____, Describe: _______________________________
_______________________________________________________________________
f. Cold: Normal _____, Abnormal _____, Describe: _______________________________
_______________________________________________________________________
g. Any numbness? No _____, Yes _____, Describe: _______________________________
_______________________________________________________________________
h. Any tingling? No _____, Yes _____, Describe: __________________________________
_______________________________________________________________________
6. Smell
a. Right Nostril: Normal _____, Abnormal _____, Describe: _________________________
_______________________________________________________________________
b. Left Nostril: Normal _____, Abnormal _____, Describe: __________________________
_______________________________________________________________________
7. Cranial Nerves: Normal _____ Abnormal _____, Describe: _______________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
8. Cerebellar Exam (Romberg, balance, gait, coordination, etc.)
Normal _____, Abnormal _____, Describe: ____________________________________
_______________________________________________________________________
_______________________________________________________________________
9. Reflexes: Normal _____, Abnormal _____, Describe: ___________________________________
_______________________________________________________________________
10. Any enlarged lymph nodes in the neck? No _____, Yes _____
a. Location and size: __________________________________
11. General Appearance:
a. Hair: _________________________________________________________________
b. Skin: _________________________________________________________________
c. Nails: ________________________________________________________________
d. Body Odors: ___________________________________________________________

SUBJECTIVE:
1. How would you describe your usual health status?
Good _____, Fair _____, Poor _____
2. Are you satisfied with your usual health status?
Yes _____, No _____, Source of Dissatisfaction: ____________________________________
8
 3. Tobacco use? No _____, Yes _____, Number of packs per day? ________________________
4. Alcohol use? No _____, Yes _____, How much and what kind? ________________________
5. Street drug use? No _____, Yes _____, What and how much? ________________________
6. Any history of chronic disease? No _____, Yes _____, Describe: ________________________
____________________________________________________________________
7. Immunization history: Tetanus __________, Pneumonia __________, Influenza __________
MMR __________, Polio __________, Hepatitis B __________
8. Have you sought any health care assistance in the past year? No _____, Yes _____
If yes, why? _________________________________________________________
9. Are you currently working? No _____, Yes _____
How would you rate your working conditions? (e.g. safety, noise, space, heating, cooling, water, ventilation):
Excellent _____, Good _____, Fair _____, Poor _____,
Describe any problem areas: ____________________________________________
____________________________________________________________________
10. How would you rate living conditions at home?
Excellent _____, Good _____, Fair _____, Poor _____
Describe: ___________________________________________________________
___________________________________________________________________
11. Do you have any difficulty securing any of the following services?
Grocery store: Yes _____, No _____; Pharmacy: Yes _____, No _____
Health Care Facility: Yes _____, No _____; Transportation: Yes _____, No _____
Telephone (for police, fire, ambulance): Yes _____, No _____
If any difficulties, note referral here: _______________________________________
__________________________________________________________________
12. Medications (over-the-counter and prescription):

Name of Drug Dosage Times/day Reason Taken as

Ordered
Yes No
1.
2.
3.
4.
5.

13. Have you followed the routine prescribed for you? Yes _____, No _____
Why not? ___________________________________________________________
14. Did you think this prescribed routing was best for you? Yes _____, No _____
What would be better? ________________________________________________
15. Have you had any accident/injuries/falls in the past year? No ____, Yes _____
Describe: ___________________________________________________________
16. Have you had any problems with cuts healing? No _____, Yes _____
Describe: ___________________________________________________________
17. Do you exercise on a regular basis? No _____, Yes _____
Type and Frequency: __________________________________________________
18. Have you experienced any ringing in the ears?
Right ear: Yes _____, No _____
Left ear: Yes _____, No _____
19. Have you experienced any vertigo? Yes _____, No _____
How often and when? _________________________________________________
20. Do you regularly use seat belts? Yes _____, No _____
21. For infants and children: Are car seats used regularly? Yes _____, No _____
22. Do you have any suggestions or requests for improving your health? Yes _____, No _____
Describe: ___________________________________________________________
23. Do you do (breast/testicular) self-examination? No _____ Yes _____
How often? _________________________________________________________
9
NUTRITIONAL – METABOLIC PATTERN
OBJECTIVE:
1. Skin examination
a. Warm _____, Cool _____, Moist _____ Dry _____
b. Lesions : No _____, Yes _____, Describe: ___________________________________
c. Rash: No _____, Yes _____, Describe: _____________________________________
d. Turgor: Firm _____, Supple _____, Dehydrated _____, Fragile _____
e. Color: Pale _____, Pink _____, Dusky _____, Cyanotic _____ Jaundiced _____
Mottled _____, Others: ________________________________________________

2. Mucous Membranes
a. Mouth
i. Moist _____, Dry _____
ii. Lesions: No _____, Yes _____, Describe: _____________________________
iii. Color: Pale _____, Pink _____
iv. Teeth: Normal _____, Abnormal _____ Describe: _______________________
v. Dentures: No _____, Yes _____; Upper _____, Lower _____; Partial _____
vi. Gums: Normal _____, Abnormal _____, Describe: ______________________
vii. Tongue: Normal _____,Abnormal _____, Describe: _____________________
b. Eyes
i. Moist _____, Dry _____
ii. Color of conjunctiva: Pale _____, Pink _____, Jaundiced _____
iii. Lesions: No _____, Yes _____, Describe: _____________________________
3. Edema
a. General: No _____, Yes _____, Describe: __________________________________
Abdominal girth: __________ inches
b. Periorbital: No _____, Yes _____, Describe: __________________________________
c. Dependent: No _____, Yes _____, Describe: __________________________________
Ankle girth: Right: __________ inches; Left: __________ inches
4. Thyroid: Normal _____, Abnormal _____, Describe: __________________________________
5. Jugular vein distention: No _____, Yes _____
6. Gag reflex: Present: _____, Absent _____
7. Can patient move easily (turning, walking) Yes _____, No _____
Describe limitations: _____________________________________________________
8. Upon admission, was patient dressed appropriately for the weather? Yes _____, No _____
Describe: ______________________________________________________________

For breastfeeding mothers only:

9. Breast exam: Normal _____, Abnormal _____, Describe: _______________________________
10. If mother is breastfeeding, have infant weighed. Is infant’s weight within normal limits?
Yes _____, No _____
SUBJECTIVE:
1. Any weight gain in the last 6 months? No _____, Yes _____, Amount: __________
2. Any weight loss in the last 6 months? No _____, Yes _____, Amount: __________
3. How would you describe your appetite? Good _____, Fair _____, Poor ______
4. Do you have any food intolerance? No _____, Yes _____, Describe: _____________________
5. Do you have any dietary restrictions? (Check for those that are a part of a prescribed regimen as well as those that patient
restricts voluntarily) No _____, Yes ______
Describe: ___________________________________________________________
6. Describe an average day’s food intake for you (meals and snacks): ______________________
____________________________________________________________________________
____________________________________________________________________________
7. Describe an average day’s fluid intake for you: ______________________________________
____________________________________________________________________________

10
 8. Describe food likes and dislikes: __________________________________________________
____________________________________________________________________________
9. Would you like to: Gain weight? _____, Lose weight? _____, Neither _____
10. Any problem with:
a. Nausea: No _____, Yes _____, Describe: _________________________________
b. Vomiting: No _____, Yes _____, Describe: _________________________________
c. Swallowing: No _____, Yes _____, Describe: _________________________________
d. Chewing: No _____, Yes _____, Describe: _________________________________
e. Indigestion: No _____, Yes _____, Describe: _________________________________
11. Would you describe your usual lifestyle as: Active _____, Sedentary _____

For breastfeeding mothers only:

12. Do you have any concerns about breastfeeding? No _____, Yes _____,
Describe: ________________________________________________________________
13. Are you having any problems with breastfeeding? No _____, Yes _____
Describe: ________________________________________________________________

ELIMINATION PATTERN
OBJECTIVE:
1. Auscultate abdomen
a. Bowel sounds: Normal _____, Increased _____, Decreased _____, Absent _____
2. Palpate abdomen
a. Tender: No _____, Yes _____, Where? _____________________________________
b. Soft: No _____, Yes _____; Firm: No _____, Yes _____
c. Masses: No _____, Yes _____, Describes: ___________________________________
d. Distention (include distended bladder): No_____, Yes _____, Describe: ___________
e. Overflow urine when bladder palpated? Yes _____, No _____
3. Rectal Exam
a. Sphincter tone: Describe: ________________________________________________
b. Hemorrhoids: No _____, Yes _____, Describe: _______________________________
c. Stool in rectum: No _____, Yes _____, Describe: _____________________________
d. Impaction: No _____, Yes _____, Describe: _________________________________
e. Occult blood: No _____, Yes _____, Location: _______________________________
SUBJECTIVE:
1. What is your usual frequency of bowel movement? _________________________________
a. Have to strain to have a bowel movement? No _____, Yes _____
b. Same time each day? No _____, Yes _____
2. Has the number of bowel movement changed in the past week? No _____, Yes _____
Increased? _____, Decreased? _____
3. Character of stool
a. Consistency: Hard _____, Soft _____, Liquid _____
b. Color: Brown _____, Black _____, Yellow _____, Clay-colored _____
c. Bleeding with bowel movements: No _____, Yes _____
4. History of constipation: No _____, Yes _____, How often? ____________________________
Do you use bowel movement aids (laxatives, suppositories, diet)? No _____, Yes _____
Describe: _____________________________________________________________
5. History of diarrhea: No _____, Yes _____, When? ___________________________________
6. History of incontinence: No _____, Yes _____
Related to increased abdominal pressure (coughing, laughing, sneezing)? No _____, Yes _____
7. History of travel? No _____, Yes _____, Where? _____________________________________
8. Usual voiding pattern:
a. Frequency (times per day) _____, Decreased? _____, Increased? _____
b. Change in awareness of need to void: No _____, Yes _____
Increased? _____, Decreased? _____
c. Change in urge to void: No _____, Yes _____
Increased? _____, Decrease? _____

11
 d. Any change in amount? No _____, Yes _____
Increased? _____, Decreased? _____
e. Color: Yellow _____, Smokey _____, Dark _____
f. Incontinence: No _____, Yes _____, When? _________________________________
Difficulty holding voiding when urge to void develops? No _____, Yes _____
Have time to get to bathroom: Yes _____, No _____
How often does problem reaching bathroom occur? ___________________________
g. Retention: No _____, Yes _____, Describe: __________________________________
h. Pain/burning: No _____, Yes _____, Describe: ________________________________
i. Sensation of bladder spasms: No _____, Yes _____, When? _____________________

ACTIVITY – EXERCISE PATTERN

OBJECTIVE:
1. Cardiovascular
a. Cyanosis: No _____, Yes _____, Where? ___________________________________
b. Pulses: Easily palpable?
i. Carotid: Yes _____, No _____ v. Femoral: Yes _____, No _____
ii. Jugular: Yes _____, No _____ vi. Popliteal: Yes _____, No _____
iii. Temporal: Yes _____, No _____ vii. Postibial: Yes _____, No _____
iv. Radial: Yes _____, No _____ viii. Dorsalis Pedis: Yes _____, No _____
c. Extremities:
i. Temperature: Cold _____, Warm _____, Hot _____
ii. Capillary refill: Normal _____, Delayed _____
iii. Color: Pink _____, Pale _____, Cyanotic _____, Other _____
Describe: _________________________________________________________
iv. Homan’s sign: No _____, Yes _____
v. Nails: Normal _____, Abnormal _____, Describe: ________________________
vi. Hair distribution: Normal _____, Abnormal _____, Describe: _______________
vii. Claudication: No _____, Yes _____, Describe: ___________________________
d. Heart: PMI location: _______________
i. Abnormal rhythm: No _____, Yes _____, Describe: ______________________
ii. Abnormal sounds: No _____, Yes _____, Describe: ______________________
2. Respiratory
a. Rate: __________
b. Depth: Shallow _____, Deep _____, Abdominal _____, Diaphragmatic _____
c. Have patient cough? No _____, Yes _____
Any sputum? No _____, Yes _____, Describe: _______________________________
d. Fremitus: No _____, Yes _____
e. Any chest excursion? No _____, Yes _____; Equal _____, Unequal _____
f. Auscultate chest:
i. Any abnormal sounds (rales, rhonchi)? No _____, Yes _____, Describe: ______
g. Have patient walk in place for 3 minutes (if permissible):
i. Any shortness of breath after activity? No _____, Yes _____
ii. Any dyspnea? No _____, Yes _____
iii. BP after activity: _____/_____mmHg in (right _____/left _____) arm
iv. Respiratory rate after activity: _____ cpm
v. Pulse rate after activity: _____ bpm
3. Musculoskeletal
a. Range of motion: Normal _____, Limited _____, Describe: ______________________
b. Gait: Normal _____, Abnormal _____, Describe: ______________________________
c. Balance: Normal _____, Abnormal _____, Describe: ___________________________
d. Muscle mass/strength: Normal _____, Increased _____, Decreased _____
Describe: _____________________________________________________________
e. Hand grasp: Right: Normal _____, Decreased _____
Left: Normal _____, Decreased _____
f. Toe wiggle: Right: Normal _____, Decreased _____

12
 Left: Normal _____, Decreased _____
g. Posture: Normal _____, Kyphosis _____, Lordosis _____, Scoliosis _____
h. Deformities: No _____, Yes _____, Describe: ________________________________
i. Missing limbs: No _____, Yes _____, Where? ________________________________
j. Uses mobility aids (walker, crutches, etc)? No _____, Yes _____
Describe: ____________________________________________________________
k. Tremors: No _____, Yes _____, Describe: __________________________________
4. Spinal cord injury: No _____, Yes _____, Level: _____________________________________
5. Paralysis present: No _____, Yes _____, Where? ___________________________________
6. Developmental Assessment: Normal _____, Abnormal _____, Describe: _________________
SUBJECTIVE:
1. Have patient rate each area of self-care on a scale of 0 to 4.
0 – Completely independent
1 – Requires use of equipment or device
2 – Requires help from another person for assistance, supervision or teaching
3 – Requires help from another person and equipment device
4 – Dependent; does not participate in activity:
Feeding _____, Bathing/Hygiene _____, Dressing/Grooming _____
Toileting _____, Ambulation _____, Care of home _____, Shopping _____
Meal preparation _____, Laundry _____, Transportation _____
2. Oxygen use at home? No _____, Yes _____, Describe: _______________________________
3. How many pillows do you use to sleep on? ________________________________________
4. Do you frequently experience fatigue? No _____, Yes _____, Describe: __________________
5. How many stairs can you climb without experiencing any difficulty (can be individual number or number or flights)?
___________________________________________________________________________
6. How far can you walk without experiencing any difficulty? ___________________________
7. Has assistance at home for self-care and maintenance of home: No _____, Yes _____
Who? ____________________
If none, would you like to have or believes needs assistance: No _____, Yes _____
With what activities? _________________________________________________________
8. Occupation (if retired, former occupation): ________________________________________
9. Describe usual leisure time activities/hobbies: _____________________________________
10. Any complaints of weakness or lack of energy? No _____, Yes _____, Describe: ___________
11. Any difficulties in maintaining activities of daily living? No _____, Yes _____, Describe: _______
12. Any problems with concentration? No _____, Yes _____, Describe: _____________________

SLEEP – REST PATTERN

OBJECTIVE/SUBJECTIVE:
1. Usual sleep habits:
a. Hours per night _____
b. Naps: No _____, Yes _____ (a.m. _____, p.m. _____)
c. Feel rested? Yes _____, No _____, Describe: ________________________________
2. Any problems:
a. Difficulty going to sleep? No _____, Yes _____
b. Awakening during night? No _____, Yes _____
c. Early awakening? No _____, Yes _____
d. Insomnia? No _____, Yes _____, Describe: _________________________________
3. Methods used to promote sleep:
a. Medication: No _____, Yes _____, Name: __________________________________
b. Warm fluids: No _____, Yes _____, What? __________________________________
c. Relaxation techniques: No _____, Yes _____, Describe: ________________________

COGNITIVE – PERCEPTUAL PATTERN

OBJECTIVE:
1. Review sensory and mental status completed in health perception – health management pattern.
2. Any overt signs of pain? No _____, Yes _____, Describe: _____________________________

13
SUBJECTIVE:
1. Pain
a. Location (have patient point to area): ______________________________________
b. Intensity (have patient rank on scale of 0 to 10): ______________________________
c. Radiation: No _____, Yes _____, To where? _________________________________
d. Timing (how often, related to any specific events): ____________________________
e. Duration: _____________________
f. What was done to relieve at home? _______________________________________
g. When did pain begin? ____________________
2. Decision-making
a. Decision-making is:Easy _____, Moderately easy _____ Moderately difficult _____, Difficult _____
b. Inclined to make decisions: Rapidly _____, Slowly _____, Delay _____
3. Knowledge level
a. Can define what current problem is: Yes _____, No _____
b. Can restate current therapeutic regimen: Yes _____, No _____

SELF-PERCEPTION AND SELF-CONCEPT PATTERN

OBJECTIVE:
1. During this assessment, does patient appear:
Calm _____, Anxious _____, Irritable _____, Withdrawn _____, Restless _____
2. Did any physiologic parameters change?
a. Face reddened: No _____, Yes _____
b. Voice volume changed: No _____, Yes _____; Louder _____, Softer _____
c. Voice quality changed: No _____, Yes _____; Quavering _____, Hesitation _____
Others: __________________________________________________________
3. Body language observed: _____________________________________________________
4. Is current admission going to result in a body structure/function change for the patient?
No _____, Yes _____, Unsure at this time _____
SUBJECTIVE:
1. What is your major concern at the current time? ____________________________________
2. Do you think this admission will cause any lifestyle changes for you? No _____, Yes _____
What? ___________________________________________________________________
3. Do you think this admission will result in any body changes for you? No _____, Yes _____
What? ___________________________________________________________________
4. My usual view of myself is: Positive _____, Neutral _____, Somewhat negative _____
5. Do you believe you will have any problems dealing with your current health situation?
No _____, Yes _____, Describe: ________________________________________________
6. On a scale of 0 to 5, rank your perception of your level of control in this situation: ____________
_________________________________________________________________________
7. On a scale of 0 to 5, rank your usual assertiveness level: ______________________________

ROLE – RELATIONSHIP PATTERN

OBJECTIVE:
1. Speech Pattern
a. Is English the patient’s native language? Yes _____, No _____
Native language is: ____________________; Interpreter needed? No _____, Yes _____
b. During interview, have you noticed any speech problems? No _____, Yes _____
Describe: ___________________________________________________________
2. Family Interaction
a. During interview, have you observed any dysfunctional family interactions?
No _____, Yes _____, Describe: __________________________________________
b. If patient is a child, is there any physical or emotional evidence of physical or psychosocial abuse? No _____, Yes
_____, Describe: __________________________

SUBJECTIVE:
1. Does patient live alone? Yes _____, No _____, With whom? __________________________

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 2. Is patient married? Yes _____, No _____; Children? No _____, Yes _____
Ages of Children: ____________________________________________________________
3. How would you rate your parenting skills? Not applicable _____
No difficulty _____, Average _____, Some difficulty _____, Describe: ___________________
4. Any losses (physical, psychological, social) in past year? No _____, Yes _____
Describe: __________________________________________________________________
5. How is patient handling this loss at this time? ______________________________________
6. Do you believe this admission will result in any type of loss? No _____, Yes _____
Describe: ______________________________________________________________________
7. Ask both patient and family: do you think this admission will cause any significant changes in the patient’s usual family role?
No _____, Yes ______, Describe: ____________________________
8. How would you rate usual social activities?
Very active _____, Active _____, Limited _____, None _____
9. How would you rate your comfort in social situations?
Comfortable _____, Uncomfortable _____
10. What activities or jobs do you like to do? Describe: _____________________________________
11. What activities or jobs do you dislike doing? Describe: __________________________________

SEXUALITY – REPRODUCTIVE PATTERN

OBJECTIVE:
Review admission physical exam for results of pelvic and rectal exams. If results are not documented, perform exams.
Check history to see if admission resulted from a rape.
SUBJECTIVE:
Female
1. Date of LMP: ____________________
Any pregnancies? Para _____, Gravida _____
Menopause? No _____, Year _____, Year __________
2. Use of birth control measures? No _____, N/A _____, Yes _____, Type: _________________
3. History of vaginal discharge, bleeding, lesions: No _____, Yes _____
Describe: ____________________________________________________________________
4. Pap smear annually: Yes _____, No _____, Date of last pap smear: _____________________
5. Date of last mammogram: ____________________
6. History of sexually transmitted disease: No _____, Yes _____, Describe: _________________
7. Is patient describing numerous physical symptoms? No _____, Yes _____
Describe: ____________________________________________________________________
8. Is patient exhibiting numerous emotional symptoms? No _____, Yes _____
Describe: ____________________________________________________________________
9. What has been your primary coping mechanism in handling this rape episode? (if applicable)
____________________________________________________________________________
10. Have you talked to persons from the rape crisis center? Yes _____, No _____
Male
1. History of prostate problems? No _____, Yes _____, Describe: _________________________
2. History of penile discharge, bleeding, lesions: No _____, Yes _____, Describe: _____________
3. Date of last prostate exam: ____________________
4. History of sexually transmitted diseases: No _____, Yes _____, Describe: _________________

Both
1. Are you experiencing any problems in sexual functioning? No _____, Yes _____
Describe: ____________________________________________________________________
2. Are you satisfied with your sexual relationship? Yes _____, No _____
Describe: ____________________________________________________________________
3. Do you believe this admission will have any impact on sexual functioning? No _____, Yes _____
Describe: _____________________________________________________________________

COPING – STRESS TOLERANCE PATTERN

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OBJECTIVE:
1. Observe behaviour:
a. Are there any overt signs of stress (crying, , clenched fists, etc.)?
Describe: ____________________________________________________________
SUBJECTIVE:
1. Have you experienced any stressful or traumatic events in the past year in addition to this admission? No _____, Yes _____,
Describe: _______________________________________
2. How would you rate your usual handling of stress? Good _____, Average _____, Poor _____
3. What is the primary way you deal with stress or problems? ____________________________
4. Have you or your family used any support or counselling groups in the past year?
No _____, Yes _____, Group name: ____________________
Was the support group helpful? Yes _____, No _____,
Additional comments: __________________________________________________________
5. What do you believe is the primary reason behind a need for this admission?
6. How soon, after first noting the symptoms, did you seek health care assistance?
7. Are you satisfied with the care you have been receiving at home? No _____, Yes _____
Comments: ___________________________________________________________________
8. Ask primary caregiver (significant other): what is your understanding of the care that will be needed when the patient goes
home? ______________________________________________________________________

VALUE –BELIEF PATTERN

OBJECTIVE:
1. Observe behaviour. Is the patient exhibiting any signs of alteration in mood? (anger, crying, withdrawal, etc)? Describe:
___________________________________________________________________________
SUBJECTIVE:
1. Satisfied with the way your life has been developing? Yes _____, No _____
Comments: _________________________________________________________________
2. Will this admission interfere with you plans for the future? No _____, Yes _____
How: ______________________________________________________________________
3. Religion: Catholic _____, Protestant _____, Jewish _____, Muslim _____, Buddhist _____
None ______, Other: ____________________
4. Will this admission interfere with your spiritual or religious practices? No _____, Yes _____
How? _____________________________________________________________________
5. Any religious restrictions to care (diet, blood transfusions)? No _____, Yes _____
Describe: ___________________________________________________________________
6. Would you like to have your (priest/pastor/rabbi/hospital chaplain) contacted to visit you?
No _____, Yes _____, Who? ____________________
7. Have your religious beliefs helped you to deal with problems in the past? No _____, Yes _____
How? _____________________________________________________________________

GENERAL:
1. Is there any information we need to have that I have not covered in this interview?
No _____, Yes _____, Comments? ______________________________________________
2. Do you have any questions you need to ask me concerning your health, plan of care or this agency? No _____, Yes _____,
Questions:________________________________________
__________________________________________________________________________
3. What is the first problem you would like to have helped with? _______________________
__________________________________________________________________________

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Anatomy & Physiology (This will show a drawing of the organ affected related to the diagnosis of the patient.)

Followed by:
Parts of the organ and functions of each part
Definition of the disease:
Clinical Manifestation/Signs & Symptoms

17
Problem List

Number of Focus / Nursing Diagnosis

Priority
1

Bibliography (a summary of all the resources used)

18
19
Defining Nursing Scientific Analysis Goal of Care Intervention Rationale
Characteristics Diagnosis
Independent

Dependent

Collaborative

Source: Title of the book, author, page

no., edition, volume

Source: Title of the

book, author, page
no., edition, volume

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FDAR

It is a method of charting nurses use, along with other disciplines, to help focus on a specific
patient problem, concern, or event. It is geared to save time and decrease duplicate charting. It is a great
charting method for nurses who have a lot of patients and is easier read by other professionals. It gives
other professionals a snapshot of what went on during your shift in a concise manner.

F (Focus): This is the subject/purpose for the note. The focus can be:
Nursing diagnosis
Event (admission, transfer, discharge teaching etc.)
Patient Event or Concern (code blue, vomiting, coughing)

D (Data): This is written in the narrative and contains only subjective (what they patient says and things
that are not measurable) & objective data (what you assess/findings, vital signs and things
that are measurable). This lays the supporting evidence for why you are writing the note.
You are letting the reader know “this is what the patient is saying and what I’m seeing”.

A (Action): This is the “verb” area. In this section, you are going to write here what you did about the
findings you found in the data part of the note. This includes your nursing interventions
(calling the doctor, repositioning, administering pain medication etc.)

R (Response): This is where you write how the patient responded to your action. Sometimes, you won’t
chart the response for several minutes or hours later.

Date Focus Time DAR

11/20/17 Watery stools 8am D : “Nagsige ra gyud kug kalibanga day” as verbalized,
Received patient sitting on the chair with ongoing IVF #1
D5LR 1L at 40 gtts/min, infusing well at left arm, exhibits
dry oral mucosa, with poor skin turgor, sunken eyes
noted, passes out foul-smelling mucoid and blood tinged
watery stools 5x approx. ½ glass in amount per
episode, with the following vital signs : BP: 130/90
TEMP : 37.8 C PR: 92 bpm RR: 24 bpm
A: Assessed the degree of dehydration, increased oral fluid
intake in volume per volume replacement, served food
rich in potassium and sodium content, low in fat, low in
fiber, restricted to eat chocolate colored foods,
monitored vital signs and charted, Monitored color,
frequency, consistency, amount of stools, gave ORS as
ordered, monitored IVF and regulated to its desired rate.
1pm R: BM 2x with particles

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Discharge Planning

AMETHOD of discharge planning was developed and modified to provide a systematic method for
ensuring client’s needs during the termination phase of hospitalization. The AMETHOD represent areas the
nurse should consider before the client goes home. The Discharge plan follows the FDAR format.
AMETHOD is placed in the Implementation.

Date Focus Time DAR

11/20/17 Discharges instructions 10am D: With discharge order from attending physician Dr._____

A: A ctivity: the client is assisted in attaining his or her

highest level of mobility possible before
discharge.
M edication: The client knows the name, action,
purpose, dose, route of administration and
side effects of each drug he or she is taking.
E nvironment: any actual or potential hazards in the
home or remedies. Homemaking services
and emotional and economic support systems
are in place.
T reatment: the client and family will know the purpose
and action of any treatment.
H ealth Teaching:the client and family is taught how to
administer drugs and treatments when
necessary. The client will also be able to
describe how his or her disease affects his or
her body,lifestyle and significant others. He
will be able to identify and report signs and
symptoms of potential health problems as well
as drug and treatment side effects.
O utpatient Referral: Follow-up care in the clinics,
hospitals, offices, etc. will be arranged. The
client will know times, dates and location of
appointments. He will also have available
telephone numbers of referred physicians and
agencies. A written discharge will be provided.
It will be reviewed and explained to the client
and family.
D iet: the client will describe his or her diet and its
purpose. He will list recommended and
restricted foods.

R: Out of the room per wheelchair with improved

condition

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