Daily Charting 1
Student:
Name (initials only): Age:
Legal Status
(Vol, 5150, 5250, Conservatorship, T-Con):
Date of Admission:
Language:
Marital Status:
Education:
Ethnicity:
Occupation:
Psychiatric Diagnosis (Axis I):
Personality Disorder / Mental Retardation (Axis II):
Psychosocial and Environmental Problems (Axis IV):
(problems with primary support group, education, occupational, housing, economic, access to heath care)
Global Assessment of Functioning (Axis V):
Date:
Sex:
Reason for hospitalization (Client’s own words):
Current stressors:
Appearance
(e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy make up)
:
Behavior & Motor Activity
(Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other)
:

Daily Charting 2
Attitude
(cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent)
:
Affect
(blunted, flat, guarded, labile, expansive, sad, other)
:
Mood
(euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, other)
:
Speech
(normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred, pressured, other)
:
Thought Content:
Suicide Ideation:
Homicidal Ideation:
Hallucinations
(auditory, visual, olfactory, gustatory, tactile)
:
Delusions
( bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious, erotomania):
Thought Process
(logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose association, preservation, rumination, confabulations, confusion, other)
:
Cognition
(orientation, memory recall, concentration, attention span)
:
Insight: Judgment:
Coordination/gait/notable movement:
Cultural issues and religious affiliation that may affect his/her care:
Familial Concerns:
Vital Signs T: P: R:
Pain (Numeric 1-10): Location: Character:
How would you describe your health: Excellent Average
Medical and (or) physical problems:
BP:
Good Poor

Nutritional Status: Diet: Feeding supplement:
Chewing difficulty:
Elimination Pattern:
Activity-Exercise Pattern:
Sleep-Rest Pattern:
Substance Abuse:
Substance Amount / Frequency Duration
Signs of withdrawal symptoms:
Teaching assessment:
Discharge Plans:
Additional data:
Daily Charting 3
Swallowing difficulty:
Last Used

Daily Charting 4
2.
3.
4.
Based on the nursing assessment you have just completed, Identify subjective and objective data and list all nursing problems including cultural issues and teaching needs (Prioritize Problems):
1.
Nursing Diagnosis (Actual or Potential):
Outcomes / Planning (measurable):
Interventions:
Evaluation (patient response to interventions):