I.

Demographic Data

Name:
Age:
Sex:
Birthday:
Birthplace:
Address:
Civil Status:
Religion:
Nationality:
Highest Educational Attainment:
Occupation:
Date Admitted:
Time Admitted:
Chief Complaints:
Admitting Diagnosis:
II.
III.
IV.
V.

History of Present Illness

Past Medical History
Family Illness History
A. Course of Confinement

B. Diagnostics:
C. List of All Drugs
VI.

Physical Assessment
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.

VII.

Psychological Status
Mental & Emotional Status
Environment Status
Sensory Status
Motor Status
Nutritional Status
Elimination Status
Fluids & Electrolytes Status
Circulatory Status
Respiratory Status
Temperature Status
IntegumentaryStatus
Comfort and Rest Status
Drug Guide

VIII.
IX.
X.

Pathophysiology
General Information About the Disease.
Nursing Care Plan