Immersion Docu (2014)

The Royal and Pontifical Catholic University of the Philippines
UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING

FORMAT OF DOCUMENTATION FOR COMMUNITY ORGANIZING
Title page and Cover Page
The Royal and Pontifical Catholic University of the

Philippines
UNIVERSITY OF SANTO TOMAS
Espana, Manila
COMMUNITY ORGANIZING PARTICIPATORY ACTION
RESEARCH
IN (Name of Community)
Presented to the
COLLEGE OF NURSING
In partial fulfillment of the requirements in
COMMUNITY HEALTH NURSING
By
Group 1 Section 1 Class 2020
(Name of Students)
Submitted to
(Name of Clinical Instructor)
(month, day,year of shifting)
Title Page
Abstract
Table of Contents
Page
Chapter 1: Introduction
A. Background
B. Statement of Objectives
C. Scope and Limitations
Chapter 2: Research Method
A. Action Research
B. Population
C. Instruments
D. Data Collection
E. Ethical Considerations
Chapter 3: Community Diagnosis
Community Health Nursing- Related Learning Experience

A. Setting of the Community
1. Description
2. Spot Map
3. Organizational Structure of the Community
B. Demographic Indices
1. Total population
2. Total families
3. Age and Gender
4. Civil Status
C. Socio-Cultural Indices
1. Educational Attainment
2. Religion
3. Place of Origin
4. Length of Residency
D. Economic Indices
1. Dependency Ratio
2. Sources of Income
3. Occupation
4. Monthly Income
5. Business Establishments
E. Health Indices
1. Medical Conditions
1.1Pregnant and Post Partum women
1.1.1 Pregnant women without pre-natal check-up
1.1.2 Reasons of pregnant women without pre-natal check-up
1.1.3 Pregnant women without Tetanus Toxoid immunization
1.1.4 Pregnant women without Iron supplementation
1.1.5 Pregnant women without Vitamin A supplementation
1.1.6 Post-partum women with post-partum follow up
1.1.7 Reasons of post-partum women without post-partum follow
up
1.1.8 Post-partum women without Tetanus Toxoid immunization
1.1.9 Post-partum women without Iron supplementation
1.1.10Post-partum women without Vitamin A supplementation
1.2Past Illness
1.2.1
Past illness without medical attendance
1.2.2
Reasons of families with past illness without medical
attendance
1.2.3
Causes of Morbidity
1.3Present Illness
1.3.1 Present illness without medical attendance
1.3.2 Reasons of families with present illness without medical
attendance
1.3.3 Point Prevalence of Present Illness

1.4Deaths
1.4.1 Deaths without medical attendance
1.4.2 Reasons of death without medical attendance
1.4.3 Causes of Mortality
1.4.4 Swaroops Index
1.4.5 Cause of death among Elderly
1.4.6 Cause of death among adult
1.4.7 Cause of death among 0-5 y/o
2. Family Planning Practices
3. Health Seeking Behavior
4. Primary Sources of Health Information
5. Infant Feeding Practices
6. Nutrition Status of Children aged 0-12 y/o
7. Deworming Status of Children aged 1 -12 y/o
8. Vitamin A Supplementation Status of Children aged 6 months-6 y/o
9. Immunization Status of Children 0- 15 months
F. Environmental Indices
1. House Ownership
2. Lot Ownership
3. Ventilation
4. Type of Housing
5. Electricity
6. Privacy
7. Food Storage
8. Water Supply
9. Excreta Disposal
10.Refuse Disposal
11.Insect and Vermin Control
12.Domestic Animals
G. Summary
H. Problem Identification and Analysis
1. Health Status
2. Health Resources
3. Health Related
I. Problem Prioritization
Chapter 4: Community Development Plan
A. HELPS Community Action Plan
1. Health
2. Education
3. Livelihood
4. Physical Environment
5. Socio-Cultural/Spiritual
B. Community Project Plan
C. Community Budget Plan

D.
E.
F.
G.
1.
2.
Health Education Plan

Organizational Structure of the Community Development Team
Committees and Functions of the Community Development Team
Minute Meeting of the Community Development Team
Chapter 5. Community Project Evaluation
A.
Overview of the Project
B.
Activities Done
C.
List of Participants
D.
Project Expense Report
E.
Project Evaluation
Participants Evaluation
Community Development Team Evaluation
Chapter 6. Public Health Nursing Activities
A. Health Service Profile
Chapter 7. Conclusion and Recommendation
A. Conclusion
B. Recommendation
1. Community
2. Community Development Team
C. Students learning experiences, insights, or realization
Appendix
A. Communication Letters
B. Instruments
C. Financial Report
D. Photo Documentation
E. Gantt Chart of Activities
Curriculum Vitae
Chapter 1. Introduction:
A. Background (describe clearly community health nursing practice in the
field of community organizing and substantiate the significant role of the
nurse in building healthy communities using participatory action research)
B. Statement of Objectives of PAR
1. General Objectives (statement of the general outcome)
2. Specific Objectives (statement of the task or what are to be
accomplished)
C. Scope and Limitation
(Describe the limitations or research barriers that exist in reference to the
participants of research and population groups participated in the
program, area of research, time of the study or implementation of the
program that came across in the study. The limitation must be
substantial, and may be methodological, practical, or ethical)

Chapter 2. Research Method
A. Action Research (describe what is Action Research)
B. Population (describe the characteristics of the participants involved in the
action program e.g. children, elderly)
C. Instruments (specify and describe the instruments used in data gathering
such as survey questionnaires, interview protocol, weighing scale, etc.)
D. Data Collection (describe how data is gathered in the community such as
house to house survey, focus group discussion, scheduled interview as
basis for planning program)
E. Ethical Considerations
Chapter 3. Community Diagnosis
A. Setting of the community
1. Description (describes the geographic boundaries from north to south
and west to east direction; distance from manila, total population of
municipality or barangay; type of neighborhood whether urban or rural,
subdivision or slum area, residential or commercial; physical facilities
like schools, church/chapel, health center or hospital, recreation, police
station, communication facilities, public market, commercial
establishments; climate; traffic patterns; means of transportation,
natural resources available in the community; sources of pollution;
energy and water sources)
2. Spot Map (construct a map of the barangay with the geographic
boundaries following north, south, west, and east directions. Indicate
in the map the houses surveyed, and the location of the facilities in the
barangay such as the barangay hall, health center/RHU/ BHS/hospital,
school, market, church, public faucet, police station, park, and other
natural resources visible in the barangay)
3. Organizational Structure of the Community (make an organizational
chart, indicate the name, position, and the photo of the members)
B. Demographic Indices
1. Total population
2. Total families
3. Age and Gender Distribution
(Table Title:)
AGE IN YEARS
M
%
F
%
N
%
0-4
5-9
10-14
15-19
20-24
25-29
30-34

35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
TOTAL
3.1Sex Ratio= Total of number of Males/Total number of Females x 100

Analysis:
3.2Age Distribution
Analysis:
For the ANALYSIS of each category, explain the reason for the existence of
the data, its implication to the community, advantages/disadvantages, and
relationship with other data. Analysis should be in narrative form.
Indicate the Title of the Table at the top of each table: Percentage
Distribution of Category, at Sitio (Name), Bgy. (Name), (Area) as of
(Month), (Year).
3.3Age and Sex Pyramid (Figure 1- Make a Population Pyramid)
(use color legend: male-blue, female-red)
(Graph Title)
Analysis: (describe the population pyramid in the barangay)

4. Civil Status (based on the number of population aged 15 y/o and
above)
Table Title
CIVIL STATUS
N
%
Single
Married
Widowed
Separated
Live-In
TOTAL
Analysis:
C. Socio-Cultural Indices
1. Educational Attainment (based on the total number population aged 7
y/o and above)
Table Title
EDUCATIONAL ATTAINMENT
N
%
No Formal Education
Elementary Level
Elementary Graduate
High School Level
High School Graduate
Vocational
College Level
College Graduate
TOTAL
Analysis:
1.1 Literacy Rate= Number of Population who can read and write x 100
Total number of Population
Analysis:
2. Religion (based on the total number of father and mother)
Table Title
RELIGION
N
%
(ex. Catholic)
TOTAL
Analysis:
3. Place of Origin (based on the total number of father & mother)
Table Title
PLACE OF ORIGIN
N
%
(ex. NCR)
TOTAL
Analysis:
4. Length of Residency (based on the total number of father & mother)
Table Title
LENGTH OF RESIDENCY
N
%

(ex. less than a year)
(ex. 1-5 years)
TOTAL
Analysis:
D. Economic Indices
1. Dependency Ratio
Table Title
AGE OF DEPENDENTS
0-14 y/o
65 y/o and above
TOTAL
Dependency Ratio (DR) % = Total # of Population 0-14 yrs. Old + 65 yrs.

Old and above x 100
Total # of Population 15 to 64 years old
Analysis:
2. Source of Income
Table Title
SOURCES OF INCOME
N
%
Employed
Self-Employed
TOTAL
Analysis:
3. Occupation
Table Title
OCCUPATION
N
%
(eg. Factory Worker)
TOTAL
Analysis:
4. Monthly Income
Table Title
MONTHLY INCOME IN PESOS
N
%
(eg. Less than 5,OOO)
TOTAL
Analysis:
5. Business Establishment
Table Title
BUSINESS ESTABLISHMENTS
(eg. Sari-Sari Store)
(eg. Canteen)
TOTAL
Analysis:

E. Health Indices
1. Medical Conditions
1.1 Pregnant and Post Partum Women
1.1.1 Pregnant women with and without Pre-natal check-up
Table Title
N
PREGNANT WOMEN
N
%
1ST
TRI
2ND
TRI
3RD
TRI
With Pre-Natal check-up

Without Pre-Natal checkup
TOTAL
Analysis:
1.1.2 Reasons of pregnant women without pre-natal check-up
Table Title
REASONS
N
%
(eg. Financial constraint)
(eg. Inaccessible health facility)
TOTAL
Analysis:
1.1.3 Pregnant women with and without Tetanus Toxoid (TT)
immunization
Table Title
PREGNANT WOMEN
N
%
With Tetanus Toxoid immunization
Without Tetanus Toxoid Immunization
TOTAL
Analysis:
1.1.4 Pregnant women with and without Iron supplements
(starting on 1st-3rd Tri)
Table Title
PREGNANT WOMEN
N
%
Taking Iron Supplements
Not Taking Iron Supplements
TOTAL
Analysis:
1.1.5 Pregnant women with and without Vitamin A
Supplementation (within 2nd-3rd tri)
Table Title
PREGNANT WOMEN
N
Taking Vitamin A Supplements
Not Taking Vitamin A Supplements
TOTAL

Analysis:
1.1.6 Post-partum women with and without post-partum follow-up
Table Title
POST-PARTUM WOMEN
With post-partum follow up

Without post-partum follow up
TOTAL
Analysis:
1.1.7 Reasons of post-partum women without Post-Partum follow up
Table Title
REASONS
N
%
TOTAL
Analysis:
1.1.8 Post-partum women with Tetanus Toxoid (TT) immunization
Table Title
PREGNANT WOMEN
N
%
With Tetanus Toxoid immunization
Without Tetanus Toxoid Immunization
TOTAL
Analysis:
1.1.9 Post-partum women taking Iron supplements (within 3 months)

Table Title
PREGNANT WOMEN
N
%
Taking Iron Supplements
Not Taking Iron Supplements
TOTAL
Analysis:
1.1.10 Post-partum women received Vitamin A supplements (within
a month)
Table Title
PREGNANT WOMEN
N
%
Received Vitamin A Supplements
10

Did not received Vitamin A Supplements
TOTAL
Analysis:
1.2 Past Illnesses
1.2.1 Past Illnesses with and without medical attendance (for
the last 5 years)
Table Title
WITH MEDICAL
WITHOUT
DISEASES
ATTENDANCE
MEDICAL
ATTENDANCE
N
%
N
%
(eg.
Hypertension)
(eg. Diarrhea)
TOTAL
Analysis:
1.2.2 Reasons of families with past illness without medical
attendance
Table Title
REASONS
N
%
TOTAL
Analysis:
1.2.3 Causes of Morbidity (identify the top ten causes of morbidity
based on the number of history of past illness)
Table Title
DISEASES
N
%
1. (eg. Hypertension)
2. (eg. Diarrhea)
TOTAL
Analysis:
1.3 Present Illnesses
1.3.1 Present Illness with and without medical attendance
Table Title
DISEASES
WITH
MEDICAL
ATTENDAN
CE
N
%
WITHOUT
MEDICAL
ATTENDANCE
N
(eg. Hypertension)
(eg. Diarrhea)
11

TOTAL
Analysis:
1.3.2 Reasons of Families with present illness without medical
attendance
Table Title
REASONS
N
%
TOTAL
Analysis:
1.3.3 Point Prevalence (PP) % = Number of existing cases of disease
at a particular point in time / Number of population at that point of
time x 100 (Compute for the PP of the top 10 causes of morbidity
based on Present Illness)
Table Title
DISEASES
N
PP
(%)
1. (eg. Hypertension)
2. (eg. Diarrhea)
TOTAL
1.4.Deaths
1.4.1 Deaths with and without medical attendance (for the last 5
years)
Table Title
WITH
WITHOUT
DISEASES
MEDICAL
MEDICAL
ATTENDAN
ATTENDANCE
CE
N
%
N
%
(eg. Hypertension)
(eg. Diarrhea)
TOTAL
Analysis:
1.4.2 Reasons of Death Without Medical Attendance (for the last 5

years)
Table Title
REASONS
(eg. Lack of financial resources)
TOTAL
12

Analysis:
1.4.3 Cause of Death Rate (CDR) % = Total # of deaths due to a
specific cause for the last 5 yrs./ Total number of population surveyed x
100 (Compute for the CDR of the top 10 causes of death in the
barangay)
Table Title
DISEASES
N
CDR (%)
1. (eg. HPN)
(eg.1 (eg.
2)
35.1%)
TOTAL
Analysis:
1.4.4 Swaroops Index (SI) % = Total # of deaths age 50 y/o and
above for the last 5 years / Total number of deaths for the last 5 years
x 100
Analysis:
1.4.5 Causes of death among Elderly
Table Title
CAUSE OF DEATH
N
%
1. (eg. HPN)
(eg.1 (eg.
2)
35.1%)
TOTAL
Analysis:
1.4.6 Causes of death among adult
Table Title
CAUSE OF DEATH
N
%
1. (eg. HPN)
(eg.1 (eg.
2)
35.1%)
TOTAL
Analysis:
1.4.7 Causes of death among 0-5 y/o (age 0-5 y/o)
Table Title
CAUSES OF DEATH
N
%
1. (eg. Diarrhea)
(eg.1 (eg.
2)
35.1%)
TOTAL
Analysis:
2. Family Planning Practices (based on the number married females age

15-45 y/o)
2.1Family Planning Acceptors
13

Table Title
FAMILY PLANNING
N
%
Acceptor
Non-Acceptor
TOTAL
Analysis:
2.2Methods Used by Acceptor
Table Title
METHODS OF FAMILY PLANNING
N
%
(eg. Calendar)
TOTAL
Analysis:
2.3Reasons of Non-Acceptor
Table Title
REASONS OF NON-ACCEPTOR
N
%
(eg. Decrease sexual satisfaction)
TOTAL
Analysis:
2.4Reasons of Drop-Out
Table Title
REASONS OF DROP-OUT
N
%
(eg. Not effective)
TOTAL
Analysis:
2.5Methods Used by Failure
Table Title
METHODS USED BY FAILURE
N
%
(eg. Condom)
TOTAL
Analysis:
3. Health Seeking Behavior of families (based on the number of families)
Table Title
HEALTH SEEKING BEHAVIOR
N
%
Traditional Healers
Health Center/RHU/BHS
Private Clinic
Public Hospital
Private Hospital
TOTAL
Analysis:
4. Primary source of health Information of families (based on the number
of families)
Table Title
PRIMARY SOURCE OF HEALTH
N
%
INFORMATION
14

Professional Health Workers
Non-Professional Health Workers
Family Members
Friends/Relatives
Mass Media
TOTAL
Analysis:
5. Infant feeding practices (for 0-1 y/o)
TYPE OF INFANT FEEDING
N
%
Breastfeeding
Bottle feeding
Mixed
TOTAL
Analysis:
6. Nutritional Status of Children (for 0-12 y/o)
Table Title
NUTRITIONAL STATUS BASED ON WT (Kg)
AGE
OVERWEIG NORM
1st
2nd
3rd N %
HT
N
AL
%
N %
Below 011 months

1-3 y/o
3-5 y/o
6-12 y/o
TOT
AL
Analysis:
7. Deworming Status of Children for the last 6 months (for 1-12 y/o)
Table Title
WITH
WITHOUT
AGE
N
%
N
%
1-3 y/o
3-5 y/o
6-12 y/o
TOTAL
Analysis:
8. Vitamin A supplements received by Children for the last 6 months (for
6 months-6 y/o)
Table Title
WITH
WITHOUT
AGE
N
%
N
%
15

6 months 1 y/o
1-3 y/o
3-6 y/o
TOTAL
Analysis
9. Immunization Status of Children (for 0-15 months)
Table Title
VACCI
NES
DOSES
1
WITH
2
3
N %
WITHOUT
2
3
N %
% N % N
N % N
% N
BCG
DPT
OPV
Hepa B
Hib
Rotavir
us
AMV
MMR
TO
TAL
Analysis:
F. Environmental Indices
1. Home Ownership
Table Title
HOME OWNERSHIP
Owned
Rented
Free
TOTAL
Analysis:
2. Lot Ownership
Table Title
LOT OWNERSHIP
Owned
Rented
Free
TOTAL
Analysis:
3. Ventilation
16

Table Title
VENTILATION
Satisfactory
Fair
Poor
TOTAL
Analysis:
4. Overcrowding
Table Title
OVERCROWDING
With
Without
TOTAL
Analysis:
5. Type of Housing
Table Title
TYPE OF HOUSE
Concrete
Light
Mixed
Makeshift
TOTAL
Analysis:
6. Electricity
Table Title
ELECTRICITY
With
Without
TOTAL
Analysis:
7. Privacy
Table Title
PRIVACY
With
Without
TOTAL
Analysis:
8. Food Storage
Table Title
FOOD STORAGE
Refrigerated
Not Refrigerated
TOTAL
Analysis:
17

9. Water Supply
Table Title
SHARED
OWNED
TYPE OF WATER SUPPLY

N
Level 1
Level 2
Level 3
TOTAL
Analysis:
10.Excreta Disposal
Table Title
SHARED
OWNED
TYPE OF EXCRETA
DISPOSAL
N
%
N
%
Level 1
Level 2
Level 3
TOTAL
Analysis:
11.Refuse Disposal
Table Title
REFUSE DISPOSAL
N
Collected
Incineration
Open Dumping
Estero
Burial
TOTAL
Analysis:
12.Insect and Vermin Control
Table Title
INSECT AND VERMIN CONTROL
N
Mechanical
Chemical
Biological
TOTAL
Analysis:
13.Domestic Animals with and without pens
Table Title
With
Without
DOMESTIC ANIMALS
Pens
Pens
N
TOTAL
18

Analysis:
G. Summary (based on the information gathered from the community in
terms of demography, socio-cultural, economic, health, and environment
written in narrative form)
H. Problems Identification and Analysis (identify at least 5 community
problems for each type)
A. Health Status
Problem Analysis
1. (eg. 80% of the mortality
(eg. TB is highly
cases are due to TB)
communicable and may cause
death if left untreated)
B. Health Resources
1.
C. Health Related
1.
I.
Prioritization of Identified Problems (Prioritize the identified community

problems. Show the score for each type of problem)
Criteria
Actual
/
Highes
t
Score
Rationale
for
Actual
Score
Weight
Criteri
a
Score
1. Nature
2.Magnitude
3.Modifiability
4.
Preventive
Potential
5. Social Concern
Total
Chapter 4. Community Development Plan
A. HELPS Community Action Plan (CAP) (Construct an action plan following the
format below for all of the problems identified and group them accordingly
to category of: H- ealth, E- ducation, L- ivelihood, P- hysical Environment, Socio-Spiritual/Cultural).
PROBLEM
(ex. Environment)
AREA
TITLE
(Formulate a title for each program based on the problem
identified)
GENERAL
OBJECTIVE
LOCUS OF
RESOURCE
COMMUNITY
SPECIFI POSSIB TIME RESPONSIB REQUIREME
19

PROBLEM
(ex. 80% of the

houses has
poor ventilation
C
OBJECTI
VES
LE
ACTIVIT
IES
FRA
ME
(ex. 1
week)
ILITY
NTS
(persons
responsible
for the
activity)
(ex. BHW)
B. Community Project Plan (CPP)

1. Project Title
2. Target Sitio & Barangay and Number of Beneficiaries
3. Project Duration
4. Project Rationale and Description (briefly describe the community and
outline of the problems and needs of the community and briefly describe how
the project intends to address the problems)
5. Project Objectives
a. General Objective (State the over-all direction/long-term objective)
b. Specific Objectives (must be specific, measurable, attainable, realistic,
and time-bound)
6. Project Phase (Narrative)
a. Preparatory Phase (explain briefly how was the project conceptualized
and planned)
b. Implementation Phase (explain briefly how the project will be
implemented, the roles of each group, partner community, and how it will
be monitored)
c. Post- Implementation Phase (explain briefly how it will be evaluated
and documented)
7. Community Participation (Describe what will be the participation of the
community members, local officials, traditional leaders, local organizations,
parish, and others)
8. Sustainability (state the over-all success, contributions, impact of the
project to the integral development of the community, and how it can be
sustain in the community)
9. Project Plan Matrix (written in bullet form)
PROJECT COST
PHASES
ACTIVITI TIME
EXPEC
RESOURCE
UST
Commun
ES
FRAM
TED
REQUIREME
Counter
ity
E
OUTPU
NTS
part
Counter
T
part
A. Preparatory
B.
Implementation
C. Evaluation
Total Cost:
C. Community Budget Plan (indicate unit, quantity, cost, amount of resource
requirements)
20

Total Cost of the Project:
Amount of UST counterpart: Php
Amount of community counterpart: Php
D. Health Education Plan (HEP)
TITLE
(ex. mothers, preschool children, toddlers, etc.)
TARGET
LEARNERS
GENERAL
OBJECTIVE
SPECIFIC
CONTENT
METHOD
TIME
RESOURCE
(outline)
(ex. Lecture,
OBJECTIVES
FRAME REQUIREME
etc.)
(use blooms
(minutes
NTS
taxonomy of
objectives for
knowledge, skill,
or attitude)
(ex. chalk, etc.)
METHOD
OF
EVALUATI
ON
(ex.
Q/A,etc.)
After (duration)
of (method), the
(learners) will be
able to:
1.
2.
3.
E. Organizational Structure of the Community Development Team
F. Committees and Functions of the Community Development Team
G. Minute Meeting of the Community Development Team (follow the format
below)
MINUTE MEETING OF THE COMMUNITY DEVELOPMENT TEAM
Meeting Date
Meeting Location
Meeting Start
Meeting End
(list all members that attended meeting)
Attendance
Meeting Apologies
(list all members that did not attend the meeting)
Recorded by
Business/Agenda
Discussion
Action
Items
(summary of the discussion
(list any decisions made or
in the meeting)
action to be taken by whom
and by when)
1. Leader Report
(reading
of
the
agenda
for
the
meeting
and
facilitate
the
approval
of
the
21

minutes
of
the
previous meeting)
2.
Committee
Report (based on
the
committee
created by the group)
3.
Old
Business
(unfinished business
from
previous
meeting)
4. New Business
(new
business
agenda)
Announcement
Future Agenda
Next Meeting
(list any special announcement made)

(list any suggested agenda items that are to be tabled for
the next meeting)
(list date/time/location of the next meeting)
Chapter 5. Community Project Evaluation (CPE)

A. Overview (title, objectives, duration, area)
B. Activities Done (what are the activities implemented before, during, after)
C. List of Participants (list of community members participated the project)
D. Project Expense Report (summary of expenses incurred for the project)
E. Project Evaluation
1. Participants Evaluation (summary evaluation from the participants in the
community)
PAGTATASA NG GAWAIN PANG PAMAYANAN
Tagapangasiwa ng Proyekto: (Year, Section, RLE Group #)
Pamagat ng Gawain:
Petsa:
Lugar:
Panuto: Ipinakikiusap na ating tasahin ang gawain ayon sa katangian nito. Lagyan
ng tsek ang naayon na kahon base sa inyong sagot.
BAHAGI NG
NAPAKAHU
SOBRANG
MAHUSA
KATAMTAM MAHIN
GAWAIN
SAY
HUSAY
Y
AN
A
5
4
3
2
1
1. Programa
2.
Tagapagsalita
3. Daloy ng
Programa
4.
Kahalagahan
ng gawain
5. Lugar
6. Tagapagorganisa
7.
Pamamahala
22

ng Oras
8.
Pamamahala
ng kalinisan
Mungkahi or komento para sa ikauunlad ng programa:
2. Students Evaluation (examine the result of the project based on
effectiveness, efficiency, appropriateness, and adequacy; examine the
participation of the community in the project)
Chapter 6. Public Health Nursing Activities (done in the BHS/HC/RHU/LyingIn/Satellite Clinic)
A. Health Service Profile
PATIENTS
AGE
SITIO/PUROK, BRGY
HEALTH
INTERVENTIO
NAME
PROBLEM
N
1.
2.
3.
Chapter 7. Conclusion, and Recommendations
A. Conclusion (based on the overall COPAR activities)
B. Recommendations
1. Community (interview the community)
2. Community Development Team (students)
C. Reflection on the learning experiences, insights, or realization (in narrative
form per student)
Appendices
A. Communication Letters
B. Instruments (Community Survey Form, Interview Guide)
C. Financial Report (Summary of all expenses incurred for all of the activities,
project implemented, transportation, food, accommodation)
D. Photo Documentation of Activities
E. Gantt Chart of the Activity (timeline of activities)
Curriculum Vitae (individual members with a 2x2picture for each)
NB:
To be submitted computerized in short bond paper with red hard bound
using Arial font 12, Single space. Attached a CD containing a soft copy of
the documentation, including the pictures for the whole duration of the
activity.
23

* Compile in a ring bind and submit the survey form of the families
surveyed in a long bond paper using Arial font 12, single space. Include
the type written survey in the CD.

FORMAT OF DOCUMENTATION FOR FAMILY HEALTH NURSING
Title page and Cover Page
The Royal and Pontifical Catholic University of the

Philippines
UNIVERSITY OF SANTO TOMAS
Espana, Manila
FAMILY HEALTH NURSING
Presented to the
COLLEGE OF NURSING
In partial fulfillment of the requirements in
By
Group 1 Section 1 Class 2020
(Name of Students)
Submitted to
(Name of Clinical Instructor)
(month, day,year of shifting)
24

Title Page
Abstract
Table of Contents
Page
Chapter 1: Introduction
A. Background
B. Statement of Objectives
C. Scope and Limitations
Chapter 2: Family Health Plan
A. Home Visit Plan
B. Family Data Base
C. Family Coping Index
D. Family Identification of Problem
E. Prioritization of Family Problems
F. Family Nursing Care Plan
Chapter 3: Conclusion, and Recommendation
A. Conclusion (based on the overall activities done during the home visit)
B. Recommendations
C. Learning experiences, insights, or realization (in narrative form per
student)
Appendices
A. Photo Documentation of Activities
Curriculum Vitae
Chapter 1. Introduction:
A. Background (describe clearly community health nursing practice in the
field of family health nursing and substantiate the significant role of the
nurse in the care of the family)
B. Statement of Objectives of Family Health Nursing
1. General Objectives (statement of the general outcome)
2. Specific Objectives (statement of the task or what are to be
accomplished)
C. Scope and Limitation
(Describe the limitations that exist in reference to the participants or
population groups participated in the program, time or implementation of
the program. The limitation must be substantial, and may be
methodological, practical, or ethical)
Chapter 2. Family Health Plan (compiled together per family)

A. Home Visit Plan
PREPARATORY PHASE
ACTUAL HOME VISIT
POST VISIT
25

1.
2.
3.
1.
2.
3.
1.
2.
3.
B. Family Data Base

C. Family Coping Index
D. Identification of Family Problems
FIRST LEVEL
SECOND LEVEL ASSESSMENT
ASSESSMENT
A. Health Deficit
Family Health Task Not Done
1.
B. Wellness Condition
1.
C. Health Threat
1.
D. Forseeable
Crisis/Stress
1.
E. Prioritization of Family Health Problems

FAMILY
PROBLEMS
NATURE
SCO
RE
REAS
ON
MODIFIABILI
TY
SCO
REAS
RE
ON
CRITERIA
PREVENTIVE
POTENTIAL
SCO
RE
REAS
ON
SALIENCE
SCO
RE
TOTAL
SCORE
REAS
ON
1.
2.
3.
F. Family Nursing Care Plan

FAMILY
PROBL
EM
FAMILY
NURSIN
G
DIAGNO
SIS
GOAL
S
OBJECTI
VES
INTERVEN
TION
TYPE
OF
FAMILY
NURSE
CONTA
CT
RESOURCE
REQUIREME
NTS
OUTCO
ME
Chapter
A.
B.
C.
3. Conclusion, Recommendations
Conclusion (based on the overall activities done during the home visit)
Recommendations
Reflection on the learning experiences, insights, or realization (in narrative
form per student)
Appendix : Photo Documentation of Activities
Curriculum Vitae (individual members with a 2x2picture for each)
26

NB:
To be submitted computerized in short bond paper with green soft bound
using Arial font 12, Single space. Attached a CD containing a soft copy of
the documentation, including the pictures for the whole duration of the
activity.
27

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The Royal and Pontifical Catholic University of the Philippines

UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING

The Royal and Pontifical Catholic University of the

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

The Royal and Pontifical Catholic University of the Philippines

The Royal and Pontifical Catholic University of the Philippines

Health Education Plan

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

3.1Sex Ratio= Total of number of Males/Total number of Females x 100

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

The Royal and Pontifical Catholic University of the Philippines

Dependency Ratio (DR) % = Total # of Population 0-14 yrs. Old + 65 yrs.

The Royal and Pontifical Catholic University of the Philippines

With Pre-Natal check-up

The Royal and Pontifical Catholic University of the Philippines

With post-partum follow up

1.1.9 Post-partum women taking Iron supplements (within 3 months)

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

1.4.2 Reasons of Death Without Medical Attendance (for the last 5

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

2. Family Planning Practices (based on the number married females age

The Royal and Pontifical Catholic University of the Philippines

The Royal and Pontifical Catholic University of the Philippines

Below 011 months

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

TYPE OF WATER SUPPLY

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

Prioritization of Identified Problems (Prioritize the identified community

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

(ex. 80% of the

B. Community Project Plan (CPP)

Community Health Nursing- Related Learning Experience

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(ex. chalk, etc.)

Community Health Nursing- Related Learning Experience

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(list any special announcement made)

Chapter 5. Community Project Evaluation (CPE)

The Royal and Pontifical Catholic University of the Philippines

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

COMMUNITY HEALTH NURSING

The Royal and Pontifical Catholic University of the

Community Health Nursing- Related Learning Experience

The Royal and Pontifical Catholic University of the Philippines

Chapter 2. Family Health Plan (compiled together per family)

Community Health Nursing- Related Learning Experience