| Patient Progress Notes |
|
Name of Student _______________________ Student Number _______________________ Hospital _______________________________ teacher name ___________________________ Clinical Area ___________________________ Week # ________________________________ Date Submitted ________________________ Mark ___________ /10
|
| BIOGRAPHIC DATA | Marks | Student Marks | |
| Patient Name (initial)
|
|
– | |
| Age
Gender |
|
1
|
|
| Admission Date |
|
||
| Admitting Diagnosis |
|
1
|
|
| Chief Complain |
|
||
| Total Marks | 2 | ||
| PRESENT ILLNES | Marks | Student Marks | |
| P | Provoke:
|
1 | |
| Palliative:
|
1 | ||
| Q | Quality:
|
1 | |
| R | Region:
|
1 | |
| Radiation:
|
|||
| S | Severity:
|
1 | |
| T | Onset:
|
1 | |
| Duration:
|
1 | ||
| Frequency: | |||
| U | Understanding Patient Perception:
|
1 | |
| Total Marks | 8 | ||
| Past history | mark | St. mark | |
| Medical & surgical | 1 | ||
| medication | 1 | ||
| immunization | |||
| Life style | 1 | ||
| Family history | |||
| Total | 3 | ||
| Literature Review
|
||
| Disease pathophysiology
(1 mark) |
Mark | |
| Clinical manifestations
(1 mark) |
||
| Assessment and diagnostic findings
(1 mark) |
||
| Medical management
(1 mark) |
||
| Nursing management
(1 mark) |
||
| Total marks 5 | ||
| PHYSICAL ASSESSMENT | |||||||
| SYSTEM | PATIENT FINDING | Marks | Student Marks | ||||
| NEURO | LOC | □Oriented □Alert □Lethargic □Sedated □Unresponsive
□Respond only to pain □Agitated □Calm □ Cry □Confused |
1 | ||||
| GCS | Motor…..…. +Verbal…..… +Eye……… = | ||||||
| Other | |||||||
| SKIN | Hair | □Thick □Thin □Dull □Shiny Color……….. | 1 | ||||
| Nail | □Flat □Curve □Convex □Clean □ Dirty □brittle Color………… | ||||||
| Skin Integrity | □Intact □Dry □ Moist □Wound □Ulcer | ||||||
| Skin Color | □Pink/WML □ Pale □Jaundiced □Cyanotic | ||||||
| Skin Temperature | □Warm □ Hot □ Cold | ||||||
| Wound/Ulcer | □None □Yes
Location………… Size……….. Border………….Depth ………… Stage……..… |
||||||
| Other | |||||||
| CARDIAC | Edema | □None □ Yes +1 / +2 / +3 / +4 Location ………. | 1 | ||||
| Capillary Refill | □Normal (1-2 seconds) □ Delayed (>3 seconds) | ||||||
| Heart Sounds | □Normal S1/S2 □Abnormal | ||||||
| Arterial Pulses | □Strong □Weak □Increased □Pounding □Absent | ||||||
| Rhythm | □Regular □ Irregular | ||||||
| Other | |||||||
| RESPIRATORY | Breath Sound | □Clear □Crackles □Wheezes | 1 | ||||
| Cough | □Absent □ Productive □ Non productive | ||||||
| Sputum/Secretion | Color……….. Consistency: □Thin □Thick | ||||||
| O2 Therapy | □None □ O2 @ …… L/M FIO2 …… % Per: | ||||||
| Other | |||||||
| Gastrointestinal | Diet | □NPO □ Reg □Clear □Soft | 1 | ||||
| Appetite | □Good □Fair □Poor □Nausea □Vomiting | ||||||
| Abdomen | □Soft □Firm □Distended | ||||||
| Bowel Sounds | □Active □Hyperactive □Hypoactive □Absent | ||||||
| Stool | □None □Formed □Soft □ Liquid Color……… LBM …../.…../…….. | ||||||
| Other | |||||||
| GENITOURINARY | Urine | □Continent □Incontinent □ Foley Color……….. | 1 | ||||
| Other | |||||||
| MUSCLOSKELETAL | ROM | □Full Limited | 1 | ||||
| Abnormality | □Absent □Present Location………. | ||||||
| Other | |||||||
| ACTIVITY | Activity | □Dependent □Independent □Bedrest | 1 | ||||
| Hygiene | □Clean □ Dirty | ||||||
| Other | |||||||
| SAFETY | Patient Safety Needs | □Call bell in reach □Bed in Low position
□Breaks on □Side Rails up □ID band on |
1 | ||||
| Other | |||||||
| ISOLATION | Isolation precaution | □Standard □Contact □Airborne □Droplet | 1 | ||||
| Other | |||||||
| Lines | Invasive Lines | Type | 1 | Site | Condition | 1 | |
|
|
|||||||
|
|
|||||||
| Total Marks | 11 | ||||||
| Lab investigation and diagnostic test | |||
| Name of test | Normal range (1) | Result (1) | Significant (1) |
| Total marks (3) | |||
| Medication (1) | ||||
| Drug name
\ Classification |
Uses
(0.5 mark) |
Side effects
(0.5 mark) |
Nursing considerations
(1 mark) |
Patient/family education
(0.5 mark) |
| Assess:
Administer: Perform/provide: Evaluate: |
||||
| Total marks (2.5) | ||||
| Medication (2) | ||||
| Drug name \ Classification
|
Uses
(0.5mark) |
Side effects
(0.5 mark) |
Nursing considerations
(1 mark) |
Patient/family education
(0.5 mark) |
| Assess:
Administer: Perform/provide: Evaluate: |
||||
| Total marks (2.5) | ||||
| PRIORITY NURSING PROBLEMS (1) |
| ACTUAL NURSIING PROCESS | Marks | Student Marks |
| Assessment : Subjective data:
|
1 | |
| Objective data:
|
1 | |
| Nursing diagnosis
|
1 | |
| Plan / Goal
|
1 | |
| Interventions (not less than 4 actions)
1. _______________________________________________________ _______________________________________________________ 2. _______________________________________________________ _______________________________________________________ 3. _______________________________________________________ _______________________________________________________ 4. _______________________________________________________ _______________________________________________________ 5. _______________________________________________________ _______________________________________________________
|
2 | |
| Evaluation
|
1 | |
| Total Marks
|
7 |
| POTENTIAL NURSING PROCESS | Marks | Student Marks |
| Nursing diagnosis
|
1 | |
| Plan / Goal
|
1 | |
| Interventions (not less than 4 actions)
1. _______________________________________________________ _______________________________________________________ 2. _______________________________________________________ _______________________________________________________ 3. _______________________________________________________ _______________________________________________________ 4. _______________________________________________________ _______________________________________________________ 5. _______________________________________________________ _______________________________________________________
|
2 | |
| Evaluation
|
1 | |
| Total Marks
|
5 |
SMMARY FOR PROGRESS NOTES:
| Student Marks | Marks | items |
| 2 | Biographic Data | |
| 8 | Present Illness | |
| 3 | Past history | |
| 5 | Literature review | |
| 11 | Physical Assessment | |
| 3 | Lad investigation and diagnostic test | |
| 5 | Medication | |
| 1 | Priority Of Nursing Process | |
| 7 | Actual Nursing Process | |
| 5 | Potential Nursing Process | |
| 50%5 = 10 | Total |
| Clinical Performance List
|
||||
| Procedure | Observe | Perform | date | Preceptor Signature |
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