Nursing Care Rendered
Nursing Care Rendered
Nursing Care Rendered
COLLEGE OF NURSING
I. PERSONAL DATA:
Name of Patient: Gender:
Address: Age:
II. HISTORY:
A. Chief Complaint:
B. Brief History:
Character:
Onset:
Location:
Duration:
Pattern:
Associated factors:
AUF-Form-CON-RLE-23
June 05, 2009 – Rev. 1
Past Health History
Social Activities:
Relationships:
AUF-Form-CON-RLE-23
June 05, 2009 – Rev. 1
Values and Belief System:
Environment:
III. ASSESSMENT:
A. Vital Signs:
Blood pressure:
Oxygen saturation:
Pulse rate:
B. Review of Systems
Eyes:
Ears:
AUF-Form-CON-RLE-23
June 05, 2009 – Rev. 1
Thorax and lungs:
Peripheral vascular:
Abdomen:
Female genitalia:
Musculoskeletal:
Neurologic:
IV. MANAGEMENT:
LIST OF
DATE AND TIME TYPE OF
MANAGEMENT DESCRIPTION RATIONALE
PERFORMED INTERVENTION
RENDERED
AUF-Form-CON-RLE-23
June 05, 2009 – Rev. 1
AUF-Form-CON-RLE-23
June 05, 2009 – Rev. 1