Patient Progress Notes
Title of Pupil _______________________
Pupil Quantity _______________________
Hospital _______________________________
trainer identify ___________________________
Scientific Space ___________________________
Week # ________________________________
Date Submitted ________________________
Mark ___________ /10
BIOGRAPHIC DATA Marks Pupil Marks
Patient Title (preliminary)
–
Age
Gender
1
Admission Date
Admitting Prognosis
1
Chief Complain
Whole Marks 2
PRESENT ILLNES Marks Pupil Marks
P Provoke:
1
Palliative:
1
Q High quality:
1
R Area:
1
Radiation:
S Severity:
1
T Onset:
1
Length:
1
Frequency:
U Understanding Patient Notion:
1
Whole Marks eight
Previous historical past mark St. mark
Medical & surgical 1
treatment 1
immunization
Life model 1
Household historical past
Whole three
Literature Assessment
Illness pathophysiology
(1 mark) Mark
Scientific manifestations
(1 mark)
Assessment and diagnostic findings
(1 mark)
Medical administration
(1 mark)
Nursing administration
(1 mark)
Whole marks 5
PHYSICAL ASSESSMENT
SYSTEM PATIENT FINDING Marks Pupil Marks
NEURO LOC □Oriented □Alert □Torpid □Sedated □Unresponsive
□Reply solely to ache □Agitated □Calm □ Cry □Confused 1
GCS Motor…..…. +Verbal…..… +Eye……… =
Different
SKIN Hair □Thick □Skinny □Boring □Shiny Shade……….. 1
Nail □Flat □Curve □Convex □Clear □ Soiled □brittle Shade…………
Pores and skin Integrity □Intact □Dry □ Moist □Wound □Ulcer
Pores and skin Shade □Pink/WML □ Pale □Jaundiced □Cyanotic
Pores and skin Temperature □Heat □ Sizzling □ Chilly
Wound/Ulcer □None □Sure
Location………… Dimension……….. Border………….Depth ………… Stage……..…
Different
CARDIAC Edema □None □ Sure +1 / +2 / +three / +four Location ………. 1
Capillary Refill □Regular (1-2 seconds) □ Delayed (>three seconds)
Coronary heart Sounds □Regular S1/S2 □Irregular
Arterial Pulses □Sturdy □Weak □Elevated □Pounding □Absent
Rhythm □Common □ Irregular
Different
RESPIRATORY Breath Sound □Clear □Crackles □Wheezes 1
Cough □Absent □ Productive □ Non productive
Sputum/Secretion Shade……….. Consistency: □Skinny □Thick
O2 Remedy □None □ O2 @ …… L/M FIO2 …… % Per:
Different
Gastrointestinal Weight loss program □NPO □ Reg □Clear □Gentle 1
Urge for food □Good □Honest □Poor □Nausea □Vomiting
Stomach □Gentle □Agency □Distended
Bowel Sounds □Lively □Hyperactive □Hypoactive □Absent
Stool □None □Fashioned □Gentle □ Liquid Shade……… LBM …../.…../……..
Different
GENITOURINARY Urine □Continent □Incontinent □ Foley Shade……….. 1
Different
MUSCLOSKELETAL ROM □Full Restricted 1
Abnormality □Absent □Current Location……….
Different
ACTIVITY Exercise □Dependent □Unbiased □Bedrest 1
Hygiene □Clear □ Soiled
Different
SAFETY Patient Security Wants □Name bell in attain □Mattress in Low place
□Breaks on □Facet Rails up □ID band on 1
Different
ISOLATION Isolation precaution □Commonplace □Contact □Airborne □Droplet 1
Different
Strains Invasive Strains Sort 1 Website Situation 1
Whole Marks 11
Lab investigation and diagnostic check
Title of check Regular vary (1) Consequence (1) Vital (1)
Whole marks (three)
Medicine (1)
Drug identify
Classification Makes use of
(zero.5 mark) Unintended effects
(zero.5 mark) Nursing concerns
(1 mark) Patient/household schooling
(zero.5 mark)
Assess:
Administer:
Carry out/present:
Consider:
Whole marks (2.5)
Medicine (2)
Drug identify Classification
Makes use of
(zero.5mark) Unintended effects
(zero.5 mark) Nursing concerns
(1 mark) Patient/household schooling
(zero.5 mark)
Assess:
Administer:
Carry out/present:
Consider:
Whole marks (2.5)
PRIORITY NURSING PROBLEMS (1)
1. _____________________________________
2. _____________________________________
three. _____________________________________
four. _____________________________________
ACTUAL NURSIING PROCESS Marks Pupil Marks
Assessment : Subjective information:
1
Goal information:
1
Nursing prognosis
1
Plan / Aim
1
Interventions (not lower than four actions)
1. _______________________________________________________
_______________________________________________________
2. _______________________________________________________
_______________________________________________________
three. _______________________________________________________
_______________________________________________________
four. _______________________________________________________
_______________________________________________________
5. _______________________________________________________
_______________________________________________________
2
Analysis
1
Whole Marks
7
POTENTIAL NURSING PROCESS Marks Pupil Marks
Nursing prognosis
1
Plan / Aim
1
Interventions (not lower than four actions)
1. _______________________________________________________
_______________________________________________________
2. _______________________________________________________
_______________________________________________________
three. _______________________________________________________
_______________________________________________________
four. _______________________________________________________
_______________________________________________________
5. _______________________________________________________
_______________________________________________________
2
Analysis
1
Whole Marks
5
SMMARY FOR PROGRESS NOTES:
Pupil Marks Marks gadgets
2 Biographic Information
eight Current Sickness
three Previous historical past
5 Literature assessment
11 Bodily Assessment
three Lad investigation and diagnostic check
5 Medicine
1 Precedence Of Nursing Course of
7 Precise Nursing Course of
5 Potential Nursing Course of
50%5 = 10 Whole
Scientific Efficiency Listing
Process Observe Carry out date Preceptor Signature
Title of Pupil _______________________ Pupil Quantity _______________________
