PERTINENT LABS

Labs ( abn &

pertinent)

Normal value

Patients value

DIAGNOSTIC STUDIES

Explain significance

Labs ( abnormal &

pertinent)

Normal value

Patients
value

Explain significance

Pt/Client Initials: ______ Room: ______ Age: ______Sex: _____ Allergies: ____________

MEDICAL CONDITION
Current Medical Diagnosis:

ASSESSMENT
Subjective:
Past Medical/Psychosocial Hx:

Objective:
PATHOPHYSIOLOGY (Include Signs and Symptoms)

NURSING DIAGNOSIS

PLANNING
STG
LTG

INTERVENTIONS

EVALUATION
(Goal/Outcome Achieved)

RATIONALE

1.

1.

2.

2.

STG

LTG
3.

3.