PSEUDO CHART

Name: Gento, Marisol Sex: F Age: 21

Room No.: 4

Date/Time Focus
10/02/21 Initial Assessment
0837 D- received patient laying down in bed. Alert and oriented. No attachments
were observed. Client is with S.O.
A- Obtained interview and Gordon’s typology. Obtained v/s
1117 Discharge Planning
D- “Igdidischarge na kuno ako yana na adlaw. Gin aareglar na kuno an mga
papeles” as verbalized by the client
- Seen and assessed by Dr. Zacale with orders of discharge for OR TECH
A- Health teaching imparted w/ emphasis on compliance w/ the treatment
regimen, nutrition, hygiene and wound care
-Instructed to comply with consultation if signs and symptoms of infection
occur.
R- Client was able to understand the health teachings and was able to recall
and distinguish medications.

MARIMIEL M. PAGULAYAN VIVIAN CEZAR, RN

STUDENT NURSE CLINICAL INSTRUCTOR