PROCESS TOOL

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Clients Initials: ____________

Clients Admission Date: _____________
Clients Room Number: ___________
Clients Age: _______
Clients Religion: _______________________
Clients Physician(s) Initials: ______________________
Clients Allergies: _________________________________________________
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8. Clients admitting diagnosis and a brief explanation of the diagnosis: _________________
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9. Clients signs and symptoms that precipitated the admission: ____________________________
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10. Clients medical history and a brief explanation of each health problem: __________________
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Type of surgery the client had (if applicable) and a brief explanation of the surgery: __________
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A list of drugs the client is receiving with an explanation of why THIS client is receiving the drug.
Also include the classification and side effects of the drugs: ______________________________
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Clients activity orders and the scientific rationale for the activity orders: __________________
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Clients diet and the scientific rationale for the diet: ___________________________________
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Clients therapies (ex: IV fluids, dressing changes, nasogastric tube, varied drains, physical
therapy, respiratory therapy, dialysis, repositioning, daily weight, intake/output, etc) and the
scientific rationale for each therapy: ____________________________________________
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16. Describe any alternative therapy the client may be receiving (ex: vitamins, acupuncture, herbs,
etc):______________________________________________________________________
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17. Prescribed pertinent diagnostic procedures with results and significance of the results: _______
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18. Prescribed laboratory tests with results and the probable cause of the abnormal values: ______
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