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Patient Care Plan and Assessment Template

This document contains patient admission information for two patients including their name, age, admitting diagnosis, past medical history, vital signs, assessments, tests, procedures, treatments, and nursing notes. Pertinent details are documented such as neurologic, respiratory, and cardiovascular exams. Medications, isolation status, and code status are also included. Shift goals and tasks are outlined.

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seaturtles505
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© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
1K views1 page

Patient Care Plan and Assessment Template

This document contains patient admission information for two patients including their name, age, admitting diagnosis, past medical history, vital signs, assessments, tests, procedures, treatments, and nursing notes. Pertinent details are documented such as neurologic, respiratory, and cardiovascular exams. Medications, isolation status, and code status are also included. Shift goals and tasks are outlined.

Uploaded by

seaturtles505
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Rm# Age: Doctor/Consults:

Reason for Admit

Name:

Rm# Age:
Abnormal and pertinent normal assessment findings: Neuro: Admit date: Resp: CV: Rhythm:

Name:

Doctor/Consults:
Reason for Admit Admit date:

Abnormal and pertinent normal assessment findings: Neuro: Resp: CV: Rhythm:

Past Medical History:


Gi/Gu: M/S: Diet: BGTs I/O: Integ: Activity: Code Status: Isolation: Pain Management:

Past Medical History:


Gi/Gu: M/S: Diet: BGTs I/O: Integ: Pain Management:

Activity:

Code Status:

Isolation:

Resp Tx: O2

Monitor:

Wt: Vital signs: T: HR: RR: BP: O2%:

Resp Tx: O2

Monitor:

Wt: Vital signs: T: HR: RR: BP: O2%:

IVs/fluids Wound/Tube Care: NG Foley Meds:

IVs/fluids Wound/Tube Care: NG Foley

I/O:

I/O:

Critical/Priority lab/diagnostic test results

Meds:

Critical/Priority lab/diagnostic test results

Allergies Nursing Notes:

Labs/Diagnostics/Procedures to be done this shift

Allergies Nursing Notes:

Labs/Diagnostics/Procedures to be done this shift

Shift Goals

Shift Goals

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