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Patient Information

Patient Information

Patient Information




Code Status:


Living Will:

Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14)

Chief Complaint

Admitting Diagnosis

Medical Management/ Orders/ Medications & Allergies (2)






RN Considerations



History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).

Medical History

Surgical History

Social History

Erickson’s Developmental Stage Related to pt. & Cite References (1)

Patient Education (In Pt.) & Discharge Planning (home needs )

Diagnostic Test/ Lab Results with dates and Normal Ranges (3)




Current Value

Concept Map

Student Name:


PC Outcomes/Goal

Priority nursing diagnosis #2

Respiratory (7)

Vital Signs (4)

Integumentary (12)

Interventions # 2

Assessment/ Evaluation #1

Assessment/ Evaluation #2

PC Evaluation Plan

Potential Complications/ at risk for

PC Interventions

Psychosocial (14)

Cardiovascular (6)

Endocrine (13)

Misc. (Ht/Wt)

GU (10)

GI (9)



Rest/ Exercise (11)

Neurological (5)

Outcome/Goal #1

Priority nursing diagnosis #1

Outcome/Goal #2

Interventions #1

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