KARDEX

Name of Patient:_______________________ Age:_____ Sex: ______ C.S.:_____

Address:______________________________ Religion:_______ Service:______ Ward:______
Date Admitted:______________________ Admitting Diagnosis:_________________________
Admitted by:_________________________Allergies:_____________________
Surgical Intervention:_____________________________ Date Discharged:_______________

Date Nursing Needs Date Nursing Intervention

Resolved
Identified

Date Diagnostic Procedure Date Treatment/Management/Diet

Date Intravenous/Blood Transfusions Date Special Endorsement

Consumed

Date Medication Ordered Date Operation Schedule if Any

 NURSING CARE MAP

Name:___________________________________________ Date Submitted: _________________

Assessment Data
Plan of Care Drug Study
(Head to Toe)

Diagnostics Lessons Learned

Name of Clinical Instructor:_______________________________ Signature: _______________

Area:__________________________________________________ Shift: ___________________
Patient’s Name:_________________________________________ Age: ____________________
Diagnosis:________________________________________________________________________
 FOCUS CHARTING

Date / Time Focus Data Action Response

Name of Clinical Instructor:_______________________________ Signature: _______________

Area:__________________________________________________ Shift: ___________________
Patient’s Name:_________________________________________ Age: ____________________
Diagnosis:________________________________________________________________________
 TEACHING PLAN

Learner’s Name:_________________________________ Age: __________________ Diagnosis_____________________________________________

Topic: ______________________________________________________________ Venue: _____________________ Duration: __________________
Goal: ______________________________________________________________________________________________________________________

Learning Outcome Content Outline Time Allotment Instructional Method Instructional Resources Evaluation
 NURSING CARE PLAN

Explanation of the
Assessment Goals and Objectives Intervention Rationale Evaluation
Problem
 DRUG STUDY

Indications and Side Effects and

Drug Drug Classification Mechanism of Action Nursing Responsibilities
Contraindications Adverse Reactions

Indications:
Generic Name:

Brand Name:

Contraindications:
Dosage, Route,
Frequency and Timing: