Republic of the Philippines

BILIRAN PROVINCE STATE UNIVERSITY

Naval, Biliran
Telefax No. (053)-500- 9045
SUC LEVEL III-A
(Per DBM-CHED Joint Circular #1-B dated June 21, 2007)
School of Nursing and Health Sciences

RELATED LEARNING EXPERIENCE CLINICAL REQUIREMENTS

Name of Student: __________________________________
Date of Experienced: __________________________________
Clinical Area: _________________________________

CONTENTS GRADE REMARKS

Nursing Assessment
 Patient History
 Gordon’s Functional Health Pattern
 Physical Assessment
Diagnostic Result/Laboratory Results
Drug Therapeutic Record
Nursing Care Plan
Focus Charting
Health Teaching Plan
Play Therapy
Discharge Plan
Disease Information
Personal Rating Scale
Time Plan

___________________________________________ _____________________________________
NAME & SIGNATURE OF STUDENT NAME & SIGNATURE OF
CLINICAL INSTRUCTOR
 Republic of the Philippines
BILIRAN PROVINCE STATE UNIVERSITY
Naval, Biliran
Telefax No. (053)-500- 9045
SUC LEVEL III-A
(Per DBM-CHED Joint Circular #1-B dated June 21, 2007)
School of Nursing and Health Sciences

PATIENT HISTORY

Name of Student:
Date of Assessment:

I. PATIENT’S PROFILE

Name of Patient: Age: Sex:

Occupation: Civil Status: Religion:
Address: Nationality:
No. of Children: Work of Husband/Wife:
Date of Admission: Time of Admission: Admitting Physician:
Chief Complain:
Admitting Diagnosis:
Source of Data:
 Republic of the Philippines
BILIRAN PROVINCE STATE UNIVERSITY
Naval, Biliran
Telefax No. (053)-500- 9045
SUC LEVEL III-A
(Per DBM-CHED Joint Circular #1-B dated June 21, 2007)
School of Nursing and Health Sciences

II. HEALTH HISTORY

 PRESENT HEALTH HISTORY

 PAST HEALTH HISTORY

 FAMILY HEALTH HISTORY

 Republic of the Philippines
BILIRAN PROVINCE STATE UNIVERSITY
Naval, Biliran
Telefax No. (053)-500- 9045
SUC LEVEL III-A
(Per DBM-CHED Joint Circular #1-B dated June 21, 2007)
School of Nursing and Health Sciences

GYNECOLOGIC HISTORY

Menarche: Telarche: Duration:

Flow: No. of Sanitary Pads:

Medical History (Reproductive System):

Surgical History (Reproductive System):

OBSTETRICAL HISTORY

LMP: AOG: EDC: GTPALM:

YEAR BIRTH ORDER AGENCY MODE OF BIRTH OUTCOME OBSTETRICIAN
DELIVERY
 Republic of the Philippines
BILIRAN PROVINCE STATE UNIVERSITY
Naval, Biliran
Telefax No. (053)-500- 9045
SUC LEVEL III-A
(Per DBM-CHED Joint Circular #1-B dated June 21, 2007)
School of Nursing and Health Sciences

GORDON’S HEALTH PROBLEM

A. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

B. NUTRITIONAL-METABOLIC PATTERN

C. ELIMINATION PATTERN
 Republic of the Philippines
BILIRAN PROVINCE STATE UNIVERSITY
Naval, Biliran
Telefax No. (053)-500- 9045
SUC LEVEL III-A
(Per DBM-CHED Joint Circular #1-B dated June 21, 2007)
School of Nursing and Health Sciences

D. ACTIVITY-EXERCISE PATTERN

E. SLEEP AND REST PATTERN

F. COGNITIVE PERCEPTUAL PATERN

 Republic of the Philippines
BILIRAN PROVINCE STATE UNIVERSITY
Naval, Biliran
Telefax No. (053)-500- 9045
SUC LEVEL III-A
(Per DBM-CHED Joint Circular #1-B dated June 21, 2007)
School of Nursing and Health Sciences

G. SELF-PERCEPTION PATTERN

H. ROLE- RELATIONSHIP PATTERN

I. SEXUALITY-SEXUAL FUNCTIONING
 Republic of the Philippines
BILIRAN PROVINCE STATE UNIVERSITY
Naval, Biliran
Telefax No. (053)-500- 9045
SUC LEVEL III-A
(Per DBM-CHED Joint Circular #1-B dated June 21, 2007)
School of Nursing and Health Sciences

J. COPING-STRESS MANAGEMENT

K. VALUE-BELIEF SYSTEM