Student Name:
Date:
Unit:
Diagnosis (Admitting/ Priority) (List one):
Lab Values and
Diagnostic Test
Results:
Fluid(s) and
Rate(s):
Patient Information
Age:
Gender:
Race:
Allergies:
Weight:
Height:
Diet:
Activity:
CODE Status:
Braden Score:
Pathophysiology (Not a definition of the disease):
Drains:
PT/OT/ST/RT/Other:
Medication(s):
Nursing Assessment Data (Subjective/Objective):
Medical/ Surgical History:
Venous
Access/Site(s):
Tubes:
Priority 1
Priority 2
Priority 3
Nursing Diagnosis (R/T) (AEB):
Nursing Diagnosis (R/T) (AEB):
Outcome (Measurable/SMART):
Outcome (Measurable/SMART):
Outcome (Measurable/SMART):
Nursing Interventions with
Rationale (Only three):
Nursing Interventions with
Rationale (Only three):
Nursing Interventions with
Rationale (Only three):
Nursing Diagnosis (R/T) (AEB):
Evaluation(met/unmet):
Evaluation(met/unmet):
Evaluation(met/unmet):
Citation(s)/ EBP:
Citation(s)/ EBP:
Citation(s)/ EBP: