Template for handout for oral process

Pt demographics (age, sex, ethnicity)

Admit date
Dates of care
Code status
Allergies
Admitting diagnosis
History of present illness (why did the client seek care? Include
events that led to the admission)
Past medical history
Pathophysiology (relate two disease processes)
Medications (PO, IV, and PRN)
Labs (pertinent to disease and patho)
Diagnostic tests (EKG, XRAY, CT, etc)
Focused assessment
Plan of care
Include the concerns you had for the client prior to care
What you actually did
What changes you would have made
**Submit a condensed (1 page only may be front and back)
handout to give to each student and the instructor. Instructor will
also need a copy of your concept maps and grading sheet for each
student.
You will be telling the story of your client. Essentially, you will
cover all aspects of the written process only in verbal format.