Students name: Chief complain:

Patients name: Age/Gender:

Attending physician: Religion:
Admitting Diagnosis: Room #:

Nursing Care Plan

Assessment Nursing Diagnosis Background Study Planning Intervention Rationale Evaluation

Resources:
Students Name: Attending physician:
Patients Name: Admitting Diagnosis:
Age: Chief Complain:
Religion: Room #:
Endorsement Assessment Medications Vital Signs

Time BP T P R O

10

11

12

INTAKE AN OUTPUT
RECEIVE: IVF FINAL: IVF URINE OUTPUT

PO PO STOOL

Date and Time: Focus: Data/Action/Response: