COX COLLEGE Springfield, Missouri NURS 105

LTC Paperwork – Clinicals Week One
LTC Physical Assessment & Health History Physical assessment 24 pts: Evaluated on completeness, terminology used, and documentation) • General Survey, • Cognition/Perception, • Activity/Exercise, • Nutrition/Metabolism, • Elimination, • Sleep / Rest, • Self-Perception / Self-Concept, • Roles / Relationships, • Coping / Stress Tolerance, • Sexuality / Reproduction, • Values/Beliefs, • Health Perception / Health Management 5 pts: (Evaluated on completeness, terminology used, and documentation) • Information reflects health assessment 5 pts: Lists:

Health History

Medications

• • • •

Medication name (generic or trade) Dosage of the medication Indicates if the dosage of the medication is within safe range. States the reason the patient is taking the medication.

Reference Page:

1 pt: Appropriately formatted reference page.

Grade ______/35