FORMAT FOR CASE STUDY

I. Introduction (include population affected and treatment)

II. Patient’s Demographic Data
III. Nursing History
a. Chief Complaint
b. History of Present Illness
c. Past Medical Health History
i. Past Hospitalizations
ii. Surgery or any invasive procedures
iii. Immunizations
iv. Intake of Maintenance Drugs
v. Accidents
vi. Common Illnesses
vii. History of Travel (foreign and local)
d. Family History
e. Socio – economic and Environmental History
IV. Physical Assessment (refer to areas of assessment on the succeeding pages)
V. Anatomy and Physiology
VI. Pathophysiology
VII. Diagnostic Studies
VIII. Theoretical Framework
IX. Pharmacology
a. Name of Drug
i. Brand and Generic Name
ii. Dose as ordered to include its frequency and mode of administration

Example: Paracetamol (biogesic) 500 mg every 6 hours p.o.

b. Action
i. General Action
ii. Specific Action
c. Indication
d. Contraindication
e. Adverse Reactions
f. Nursing Responsibilities
i. Drug Administration
ii. Monitoring
iii. Effects
iv. Client and Family Teaching
X. Problem List
a. Date Identified
b. Cues
c. Health Problem
d. Nursing Diagnosis
e. Date of Resolution
XI. Nursing Care Plan
a. Nursing Cues (Subjective, Objective and Measurable Cues)
b. Nursing Diagnosis
 c. Goals of Care
d. Intervention
e. Rationale of Interventions
f. Evaluation
XII. Discharge Plan
a. Medications
b. Exercise
c. Treatment
d. Health Education
e. OPD Follow – up
f. Diet
g. Spirituality/Sexuality