Patient Progress Notes

Patient Progress Notes

Name of Student _______________________
Student Number _______________________
Hospital _______________________________
teacher name ___________________________
Clinical Area ___________________________
Week # ________________________________
Date Submitted ________________________
Mark ___________ /10

BIOGRAPHIC DATA Marks Student Marks
Patient Name (initial)

–
Age
Gender
1

Admission Date

Admitting Diagnosis
1

Chief Complain

Total Marks 2

PRESENT ILLNES Marks Student Marks
P Provoke:
1
Palliative:
1
Q Quality:
1
R Region:
1
Radiation:

S Severity:
1
T Onset:
1
Duration:
1
Frequency:
U Understanding Patient Perception:
1
Total Marks 8

Past history mark St. mark
Medical & surgical 1
medication 1
immunization
Life style 1
Family history
Total 3

Literature Review

Disease pathophysiology
(1 mark) Mark
Clinical manifestations
(1 mark)
Assessment and diagnostic findings
(1 mark)
Medical management
(1 mark)
Nursing management
(1 mark)
Total marks 5

PHYSICAL ASSESSMENT
SYSTEM PATIENT FINDING Marks Student Marks
NEURO LOC □Oriented □Alert □Lethargic □Sedated □Unresponsive
□Respond only to pain □Agitated □Calm □ Cry □Confused 1
GCS Motor…..…. +Verbal…..… +Eye……… =
Other
SKIN Hair □Thick □Thin □Dull □Shiny Color……….. 1
Nail □Flat □Curve □Convex □Clean □ Dirty □brittle Color…………
Skin Integrity □Intact □Dry □ Moist □Wound □Ulcer
Skin Color □Pink/WML □ Pale □Jaundiced □Cyanotic
Skin Temperature □Warm □ Hot □ Cold
Wound/Ulcer □None □Yes
Location………… Size……….. Border………….Depth ………… Stage……..…
Other
CARDIAC Edema □None □ Yes +1 / +2 / +3 / +4 Location ………. 1
Capillary Refill □Normal (1-2 seconds) □ Delayed (>3 seconds)
Heart Sounds □Normal S1/S2 □Abnormal
Arterial Pulses □Strong □Weak □Increased □Pounding □Absent
Rhythm □Regular □ Irregular
Other
RESPIRATORY Breath Sound □Clear □Crackles □Wheezes 1
Cough □Absent □ Productive □ Non productive
Sputum/Secretion Color……….. Consistency: □Thin □Thick
O2 Therapy □None □ O2 @ …… L/M FIO2 …… % Per:
Other
Gastrointestinal Diet □NPO □ Reg □Clear □Soft 1
Appetite □Good □Fair □Poor □Nausea □Vomiting
Abdomen □Soft □Firm □Distended
Bowel Sounds □Active □Hyperactive □Hypoactive □Absent
Stool □None □Formed □Soft □ Liquid Color……… LBM …../.…../……..
Other
GENITOURINARY Urine □Continent □Incontinent □ Foley Color……….. 1
Other
MUSCLOSKELETAL ROM □Full Limited 1
Abnormality □Absent □Present Location……….
Other
ACTIVITY Activity □Dependent □Independent □Bedrest 1
Hygiene □Clean □ Dirty
Other
SAFETY Patient Safety Needs □Call bell in reach □Bed in Low position
□Breaks on □Side Rails up □ID band on 1
Other
ISOLATION Isolation precaution □Standard □Contact □Airborne □Droplet 1
Other
Lines Invasive Lines Type 1 Site Condition 1

Total Marks 11

Lab investigation and diagnostic test
Name of test Normal range (1) Result (1) Significant (1)

Total marks (3)

Medication (1)
Drug name
Classification Uses
(0.5 mark) Side effects
(0.5 mark) Nursing considerations
(1 mark) Patient/family education
(0.5 mark)
Assess:
Administer:
Perform/provide:
Evaluate:
Total marks (2.5)

Medication (2)
Drug name Classification
Uses
(0.5mark) Side effects
(0.5 mark) Nursing considerations
(1 mark) Patient/family education
(0.5 mark)
Assess:
Administer:
Perform/provide:
Evaluate:
Total marks (2.5)

PRIORITY NURSING PROBLEMS (1)

1. _____________________________________
2. _____________________________________
3. _____________________________________
4. _____________________________________

ACTUAL NURSIING PROCESS Marks Student Marks
Assessment : Subjective data:

1
Objective data:

1
Nursing diagnosis

1
Plan / Goal

1
Interventions (not less than 4 actions)

1. _______________________________________________________
_______________________________________________________
2. _______________________________________________________
_______________________________________________________
3. _______________________________________________________
_______________________________________________________
4. _______________________________________________________
_______________________________________________________
5. _______________________________________________________
_______________________________________________________
2
Evaluation
1
Total Marks
7

POTENTIAL NURSING PROCESS Marks Student Marks
Nursing diagnosis

1
Plan / Goal

1
Interventions (not less than 4 actions)

1. _______________________________________________________
_______________________________________________________
2. _______________________________________________________
_______________________________________________________
3. _______________________________________________________
_______________________________________________________
4. _______________________________________________________
_______________________________________________________
5. _______________________________________________________
_______________________________________________________
2
Evaluation

1
Total Marks
5

SMMARY FOR PROGRESS NOTES:

Student Marks Marks items
2 Biographic Data
8 Present Illness
3 Past history
5 Literature review
11 Physical Assessment
3 Lad investigation and diagnostic test
5 Medication
1 Priority Of Nursing Process
7 Actual Nursing Process
5 Potential Nursing Process
50%5 = 10 Total

Clinical Performance List

Procedure Observe Perform date Preceptor Signature

Name of Student _______________________ Student Number _______________________