OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING
Regalado Avenue, North Fairview Quezon City

HOSPITAL OF AFFILIATION:
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AREA/WARD:
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DATE OF CLINICAL EXPOSURE:
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DAY & TIME OF DUTY EXPOSURE:
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PATIENT PROFILE
NAME:
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ADDRESS:
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DATE ADMITTED:
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DOCTOR IN-CHARGE:

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DIAGNOSIS:
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NURSING HISTORY

PRESENT MEDCIAL/SURGICAL HISTORY

PAST MEDCIAL/SURGICAL HISTORY

DRUG STUDY
NAME
Generic/Bran
d/ dosage

INDICATION
S

CLASSIFICATIO
N

SIDE
EFFECTS

CONTRAINDICARTI
ONS

NURSING
CONSIDERATI
ONS