Concept Map (TEMPLATE)
Student Name:
Instructor:
DATE Care Provided and UNIT:
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY GOT
TO THE HOSPITAL- UNTIL NOW WHEN YOU ARE PROVIDING CARE? (USE SEPARATE ATTACHED WORD DOC  WHEN NEEDED)
Patient Information
(1)
Patient Initials:
Age & Gender:
Height/Weight:
Medical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED MEDICAL PROBLEMS
Code Status:
Living Will/ DPOA:
Chief Complaint
Surgical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED SURGICAL PROBLEMS
Admitting Diagnosis & Admission Date
Social History:
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1)
(14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial
Considerations/Concerns: include the following Social Determinants of Health (SDOH)
❋Economic Stability
( MAY DELETE THESE ‘TIPS” TO USE SPACE)
❋ Education
❋Social and Community Context
❋ Health and Health Care
❋ Neighborhood and Built Environment
(VM/GP/KL-V5)
Erickson’s Developmental Stage Related to pt. & Cite References (1)
*List and Discuss specific stage (based on objective assessment)
Concept Map (TEMPLATE)
Student Name:
Instructor:
DATE Care Provided and UNIT:
Medical Management and Collaborative Plan
(from MD, PT, OT notes….etc.) *Consider past 24 – 48 hours
Key Diagnostic Tests/ Procedures and Lab Results with Dates and Normal Ranges (3)
Lab Tests
Normal
Ranges
Admission
Lab Values
Current
Lab Values
Explain Abnormal
Labs R/T Your Pt
Patient Education (In Pt.) for Transfer/ Discharge Planning
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or
DISCHARGE
EQUIPMENT
INCLUDE:
Appropriate
Diagnostic Tests/
Procedures- DATEs
and RESULTS
(Can add  See
attached Word Doc)
(VM/GP/KL-V5)
( MAY DELETE THESE ‘TIPS” TO USE SPACE)
MEDS
TREATMENT
REFERRALS NEEDED
Medications & Allergies (2)
Medication Name
(VM/GP/KL-V5)
Dose
Route
Freq.
Indications (PRN meds must
include MD ordered Indication)
Mechanism of Action
Side Effects/
Adverse Reactions
Nursing Considerations
ASSESSMENT/
REVIEW OF SYTEMS
Concept Map (TEMPLATE)
Student Name:
Instructor:
DATE Care Provided and UNIT:
Vital Signs (4)
Neurological (5)
Musculoskeletal
(8)
GI
Hydration/Nutrition (9)
Integumentary (12)
Endocrine (13)
(VM/GP/KL-V5)
Cardiovascular (6)
Respiratory (7)
GU (10)
Rest/ Exercise (11)
Psychosocial (14)
Misc.
Concept Map (TEMPLATE)
PLAN OF CARE
Student Name:
Instructor:
DATE of Care Provided and UNIT:
Priority Nursing Diagnosis #2
Priority Nursing Diagnosis #1
Outcome/Goal #1
Outcome/Goal #1
Interventions # 2
Intervention #1
Evaluation #1
Evaluation #2
At Risk Interventions
At Risk Outcomes/
Goal
At Risk Dx.-
(VM/GP/KL-V5)
At Risk Evaluation Plan