NCM 117 RLE - Case Scenario Format

i. Introduc on
ii. Objec ves
iii. Limita ons

I. Personal Data
Name
Address
Age
Sex
Civil Status
Religion
Birthday
Birthplace
Room and Bed No.
Hospital No.
Case No.
A ending Physician – if applicable
Chief Complaint/Reason for Seeking Healthcare
Medical Diagnosis – if applicable

II. Medical History

A. History of Present Illness

B. Past Medical History

C. Family Medical History (Genogram)

D. Social History

E. Environmental History
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 III. MSE

IV. Physical Examina on / Review of System

Normal Actual Analysis/

Body Part
Findings Findings Interpreta on

V. Anatomy & Physiology

VI. Pathophysiology(Pa ent-based, concept map)

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 VII. Laboratory and Diagnos c Examina on – Recent to past

Laboratory Normal Analysis/

Results
Examina on Values Interpreta on

VIII. Medical and Surgical Interven ons

IX. Drug Study

Gener
ic
Dosage/ Mechanis Contra- Adverse Nursing
Name Classi ca Indica o
Frequen m of indica o Reac o Responsibili
and on ns
cy Ac on n ns es
Brand
Name

Note: indicate date started, shi ed, or discon nued

X. Nursing Care Plan (NCP) 3 iden ed problem with 3 interven on each problem
( dependent, independent, collabora ve)

By: ancnery
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