Client No.: …………………………………….
Name: ……………………..… ( )
Nursing Documentation (1) ID Card No.:…………….….. Sex/Age: ……....
– Nursing Health History Ward: …E0924………………Bed:…………
* Circle the appropriate option & fill in the blank
Biographical Data
Occupation: Education: Primary / Secondary / Tertiary / Others:
Marital status: Single / Married / Divorced / Separated / Widowed / Others:
Religion: Buddhism / Catholic / Christian / Muslim / Others:
Significant others or support persons (availability): No /
Yes, [specify name, (relationship) & contact]
Reason for Seeking Health Care
Difficulty breathing / Chest discomfort / Abdominal discomfort / Others:
Admission: Emergency Case / Outpatient Case / Transfer in
Time admitted: hr. Date
Transfer in from another Hospital/ Ward/ Others at hr
Mode of ward admission: Walk-in / Wheelchair / Stretcher
History of Present Health Concern
Characteristic: Onset time:
Location for discomfort: / Not applicable; Radiation: No / Yes, (specify areas)
Duration: Persistent / Intermittent / Recur / Others:
Severity for pain: Pain score (0 for pain free, 10 for the worst pain) / Not applicable
Pattern: Worse at exhaustion/ at emotional/ at rest/ Others:
Associated symptoms: Chills / Fever / Fatigue / Headaches / Indigestion / Nausea / Sweating /
Weight changes /Others:
Past Health History
Diabetes / Hypertension / Coronary heart disease / Depression / Others:
Family Health History
Diabetes / Hypertension / Coronary heart disease / Depression / Others:
Allergic History
No /
Yes, (specify if necessary): Drug Food Others:
Student No: Exam No. Date & Starting Time:
Client No.: …………………………………….
Name: ……………………..… ( )
Nursing Documentation (2) ID Card No.:…………….….. Sex/Age: ……....
Cont.– Nursing Health History Ward: …E0924………………Bed:…………
Family Assessment
Genogram
Client No.: …………………………………….
Name: ……………………..… ( )
Nursing Documentation (3)- ID Card No.:…………….….. Sex/Age: ……....
Cont. Nursing Health History
Ward: ……E0924……………Bed:…………
Review of Body Systems (By self-report)
Acuity Level: Conscious / Semiconscious / Unconscious
Mental State: Stable / Unstable: Difficulty concentrating/ Suicidal thoughts/ Others:
Emotional State: Calm / Depressed / Anxious / Angry
Vision: Normal / Correction / Blind (L/R)/ Blurring / Diplopia/ Discharge
Hearing: Normal / Aided (L/R) / Deaf (L/R) / Tinnitus / Discharge
Skin: Normal / Pallor / Cyanosis / Jaundice / Dehydration /Ankle oedema / Bruising
Rash / Sore / Wound / Scar / Others: Location: Size:
Breathing: Normal / Dyspnoea / Stertor / Others:
Coughing: Nil / Dry / Sputum (specify quality & amount)
Eating & Drinking: Normal / Anorexia / Dysphagia / Gum Problems/ Others:
Urination: Normal / Incontinence/ Dribbling / Voiding pain / Others:
Bowel Pattern: Normal / Constipation / Incontinence/ Diarrhoea / Blood in stool/ Others:
Muscle & Bone: Normal/ Cramp / Deformity / Stiffness/ Motion restriction / Paraesthesia / Others:
Lifestyle and Health Practices
Habit: Smoker / Ex-smoker /Drinker / Drug addict / Other:
Sleeping: Normal / Insomnia / Sleep disturbances / Nocturnal waking /Aided by
Self-care Ability: Self-help / Assisted / Totally dependent
Aids: Nil /Contact lens / Hearing aids / Walking aids / Prosthesis / Denture: Fixed/ Removable /
Others:
General Survey
2
BW kg, Height m, BMI= weight in kg/height in meter =
SkinT ℃, /min, RR /min, BP mmHg,
P
SpO2 % at Room air
Or SpO2 % with O2 L/min Device
Urinalysis
Sugar , Alb , WBC , RBC
* Circle the appropriate option & fill in the blank
Student No: Exam No. Date & Starting Time:
Client No.: …………………………………….
Name: ……………………..… ( )
ID Card No.:…………….….. Sex/Age: ……....
Nursing Documentation (4) Ward: ……E0924……………Bed:…………
– Physical Assessment
Physical Assessment
I. Respiratory Assessment
1. Inspection: Anteroposterior-to- transverse chest diameter ratio
2. Palpation:
3. Percussion:
4. Auscultation for quality of breath sounds on bilateral lung fields:
II. Heart Assessment
1. Auscultation for quality of heart sounds: Rate ,Rhythm ,
Intensity of S1 & S2: at the Apex.
2. ECG Lead II waveform identification:
III. Abdomen Assessment
1. Inspection: Abdomen contour ; Skin tone ;
Skin integrity
;
Umbilicus contour location .
2. Auscultation for quality of bowel sounds:
3. Percussion: Generalized predominates.
4. Responses to light palpation:
IV. Glasgow Coma Scale Score
Eye opening response Spontaneous opening 4
To verbal command 3
To pain 2
No response 1
Most appropriate verbal Oriented 5
response Confused 4
Inappropriate words 3
Incoherent 2
No response 1
Most integral motor response Obey verbal commands 6
Localizes pain 5
Withdraws from pain 4
Flexion (decorticate rigidity) 3
Extension (decerebrate rigidity) 2
No response 1
V. Pupillary response
Student No: Exam No. Date & Starting Time:
Client No.: …………………………………….
Name: ……………………..… ( )
ID Card No.:…………….….. Sex/Age: ……....
Nursing Documentation (5) Ward: …E0924………………Bed:…………
– Investigation & Results
Results and Normal References * Circle the abnormal results
Arterial Blood Gas
Carbon dioxide, partial pressure (PaCO2) (32-48 mmHg)
Hydrogen bicarbonate (HCO3) (24 -26 mEq/L)
Oxygen, partial pressure (PaO2) (83 -108 mmHg)
Oxygen saturation (SaO2) (>=95%)
pH (7.35-7.45)
Blood Picture
Haemoglobin (12-16g/DL; female) (14-18g/DL; male)
White cell count 9)
(4-11x10
Cardiac Enzymes
Creatine Kinase-MB (0-3g/L)
Renal Function Tests
Sodium (135 -145 mmol /L)
Potassium (3.5 – 5.0 mmol/L )
Blood urea nitrogen (4-8 mmol/L)
Creatinine (53-97mol/L; female) (80-115mol/L; male)
Liver Function Tests
Alanine aminotransferase (ALT) (5-40 U/L)
Aspartate aminotransferase (AST) (0.08-0.67kat/L)
Total serum bilirubin (2-20 mol/L)
Culture
Stool No unusual growth or with specification
Sputum No unusual growth or with specification
Student No: Exam No. Date & Starting Time:
Client No.: …………………………………….
Name: ……………………..… ( )
Nursing Documentation (5) ID Card No.:…………….….. Sex/Age: ……....
– Progress and Intervention Ward: …E0924………………Bed:…………
Date / Time Progress and Intervention Signature
**Use SBAR approach to write up a brief report**
Student No: Exam No. Date & Starting Time:
