Professional Documents
Culture Documents
I. SETTING OF OBJECTIVES
STATUS
SO SPECIFIC ACTIVITY NOT
REMARKS
DONE
DONE
ANNOTATED READING
Score: _____/20
Note: The original source must be photocopied and clipped to this page. The journal must be from a
known nursing journal written at least 2013 to present, at least three (3) paragraphs long, and must be
relevant to nursing practice.
Patient’s Name: ________________________ Age: ____ Gender: _______ Civil Status: _______
Address: _____________________________________________________ Ethnicity: _________
Occupation: ___________________________ Attending Physician: ________________________
GORDON’S ASSESSMENT
Score: _____/20
V. SLEEP/REST PATTERN
PHYSICAL ASSESSMENT
Score: _____/20
General Health
Survey
Integumentary
System
Neck
Respiratory
System
Cardiovascular
System
Gastrointestinal
System &
Abdomen
Genitourinary/
Reproductive
System
Musculoskeletal
System (Upper &
Lower Extremities)
Neurologic System
Lymphatic/
Hematologic
System
DRUG STUDY
Score: _____/30
DRUG DRUG
GENERIC NAME
CLASSIFICATION
INDICATIONS
MECHANISM OF
ACTION
DRUG
INTERACTIONS
NURSING
CONSIDERATIONS
PATIENT
TEACHINGS
DATE
FOCUS DATA – ACTION – RESPONSE
TIME/SHIFT
NURSING DIAGNOSTIC
STATEMENT (2- OR 3-PART)
OBJECTIVE DATA
DATE
NORMAL/
REFERENCE
VALUES
RESULT
INTERPRETATION
(RELATE WITH
DIAGNOSIS)
NURSING
RESPONSIBILITIES
(PRE- & POST-TEST)
REFERENCE/S: ______________________________________________________________________________