NURSING CARE

PLAN
Submitted to:

Submitted by:
 Demographic Information

Name: Civil Status: Religion:

Age: Occupation: Nationality:
Date of Birth: Educational Attainment:
Address: Doctor(s) in charge:
Date & time of Admission: Room & Bed No:
Chief Complaint(s):

History of present illness:

General Impression of client (appearance upon first contact):

Assessment Diagnosis Planning Interventions Rationale Evaluation
FUNCTIONAL HEALTH
PATTERN
Submitted to:

Submitted by:
USUAL FUNCTION PATTERN INITIAL APPRAISAL ONGOING APPRAISAL ONGOING APPRAISAL