– SU_NSG6001_POC_TemplateNursing2.pdf

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NAME PLAN OF CARE 2

**Please delete this statement and anything in italics prior to submission to shorten the length

of your paper.

Patient Initials ______

Subjective Data: (Information the patient tells you regarding themselves: Biased Information):

Chief Compliant: (In patient’s exact words)

History of Present Illness: (Analysis of current problems in chronologic order using symptom

analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated

symptoms and treatments tried]).

PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major

medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history,

obstetric and history sexual history).

Significant Family History: (Includes family members and specific inheritable diseases).

Social History: (Includes home living situation, marital history, cultural background, health

habits, lifestyle/recreation, religious practices, educational background, occupational history,

financial security and family history of violence).

Review of Symptoms: (Review each body system – This section you should place POSITIVE for…

information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ;

ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:;

Neurological:; Endocrine:; Hematologic:; Psychologic: .

Objective Data:

Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .

Physical Assessment Findings: (Includes full head to toe review)

HEENT:

Lymph Nodes:

Carotids:

Lungs:

Heart:

Abdomen:

Genital/Pelvic:

Rectum:

Extremities/Pulses:

Neurologic:

Laboratory and Diagnostic Test Results: (Include result and interpretation.)

Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of

priority.)

Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as

education and counseling provided).

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