1. History of Present Illness: Patient Education / Discharge Planning:
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)
Patient Education / Discharge Planning:
(Barriers to education, learning goals, learning outcomes) (Home Vs Facility, services needed after discharge, adaptive equipment needed for home.)
Erikson’s Developmental Stage Related to Pt & APA citations
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. “Risk For” Interventions
Objective Signs
Priority Nursing Diagnosis #1
Vital Signs
Neurological
Cardiovascular
Respiratory
Priority Nursing Diagnosis #2
Nutrition / Hydration GI GU
Rest / Exercise
Outcome Goal #1
(specific, measurable, achievable, realistic, time bound)
Outcome / Goal #2
Integumentary
Endocrine
Psychosocial
Musculoskeletal
Interventions #1
Evaluation #1
(start with “goal met” or “goal not met”)
Evaluation #2
Interventions #2
“Risk For” Interventions
“Risk For” Evaluation
“Risk for” Diagnosis
“Risk For” goal

3. Davis, 2015. Medication Name, Dose, Route, Freq & APA Citation
Why Pt is Taking the Drug and
Method of Action
Side Effects
Nursing Considerations
Davis, 2015.

4. References