Adult Health II
Signs and Symptoms
Expected Outcomes
Short term –
Long term –
Nursing Diagnoses
Leadership/Communication/
Professionalism
Causes
Quality Improvement
Diagnostic tests
Lab
Disease/Disorder
Acute
Chronic
Radiology
Other tests/procedures
Treatments/Medications – EBP –
Client-Centered Care
Interdisciplinary
Consults (Teamwork
& Collaboration)
Organs/System Affected
Priorities
Safety Issues/Nursing
Considerations/Patient Education
Informatics &
Technology
Adult Health II
Taylor College
Clinical Information Sheet
Student ___________________________________Date _____________
Patient
Initials/Age/Code/DOB
Diagnosis
Surgery/Procedure
Done/Results
Surgery/Procedure
Scheduled
Medical/Surgical History
Social History
Report Received
Today's Goal
Diet
Activity Level
Vitals
IV
Fluid restriction
Drains/Tubes/Incision
Blood Sugars
Allergies
Meds
Time
Meds
Time
Meds
Time
Meds
Time
Physical Assessment: Head
Lungs
LOC
Heart sounds
Pupils
Rhythm
Abdomen
Extremities
Pulses
Skin
Wounds
Cultural Needs
Family Needs/Concerns
Diagnostic Results
Adult Health II