I.

INTRODUCTION

A. Background of the Study

B. Objectives

General

Specific

C. Scope and Limitation of the Study

II. CLINICAL SUMMARY

A. General Data

Name:

Address:

Age:

Religion:

Civil Status:

Nationality:

Date of Birth:

Date and Time of Admission:

Ward/Room:

Attending/ Tentative Diagnosis:

Revised Diagnosis:

Final Diagnosis:

Date of Discharge/ Expiration/ Death:

Attending Physician:

Sources of Information:

B. Chief Complaint:

C. History of Present Illness

D. Past Medical History

E. Familial History

F. Obstetric History

G. Developmental History

H. Socioeconomic History

Physical Assessment

Findings Normal Values Analysis/

Interpretation
Measurement
Height
Weight
Vital Signs
BP
Temperature
Respiration Rate
Cardiac Rate

Body Parts Normal Findings Actual Findings Analysis and

Interpretation
A. HEAD
1. Skull
2. Hair
3. Face
4. Eye/Vision
4.1 Eyeball
4.2 Lid
Margin
4.3
Conjunctiva
4.4 Sclera
4.5 Eyebrow,
lashes, color,
symmetry,
quality of
hair,
placement
4.7 Eye
movement in
all directions
B. VISION TESTING
1. Visual
field
2. Visual
acuity
C. EARS
1. Pinna
2. External
Canal
3. Hearing
Acuity
D. NOSE
E. MOUTH/ LIPS
1. Gums
2. Teeth
3. Tongue
4. Palate
-hard/soft
5. Oropharynx/
tonsil
F. CHEEKS
G. NECK
H. CHEST
1. Anterior
2. Posterior
I. HEART
J. BREAST
K. ABDOMEN
L. UPPER
EXTREMITIES
M. LOWER
EXTREMITIES

Patterns of Functioning

Before During Analysis/

Hospitalization Hospitalization Interpretation
Nutrition
Elimination
Exercise/ Hygiene
Rest/ Sleep

III. CLINICAL DISCUSSION OF THE DISEASE

A. Anatomy and Physiology

B. Pathophysiology

C. Course in the Ward

D. Laboratory Findings

Date Findings Normal Values Analysis/

Interpretation

IV. DRUG STUDY

Generic Dosage/ Actions Side Effects Nursing

Name / Frequency/ Considerations
Classification Route / Alert

V. NURSING PROBLEMS AND PRIORITIZATION

Cues Nursing Problem Rank Justification

VI. NURSING CARE PLAN

Problem Analysis Goals/ Nursing Rationale Evaluation

Objectives Intervention
s

VII. DISCHARGE PLANNING

M- Medications

E- Exercise

T- Treatment

H- Health Teachings

O- Out-patient follow-up
D- Diet

S-Spiritual practice

VIII. COMPETENCY ACQUISITION AND SIGNIFICANCE OF THE STUDY AS TO CLINICAL

PRACTICE

IX. REFERENCES/ SOURCES