I.

Readings
II. Anatomy and Physiology
III. Pertinent Data
IV. Health History
- Family
- Past
- Present
V. Physical Assessment
VI. Pathophysiology
VII. Developmental Task
- Tasks/Achieved or Not/Justification
VIII. Patterns of Functioning
(Before hospitalization/During Hospitalization/Analysis)
- Eating
- Drinking
- Bladder
- Bowel
- Bathing
- Sleeping
IX. Level of Competencies
(Before hospitalization/During Hospitalization/Analysis)
- Physical
- Social
- Emotional
- Mental
- Spiritual
X. On –Going- Appraisal (Narrative form)
XI. Laboratory and diagnostic procedures
XII. Medical management
XIII. Drug study
XIV. NCP
XV. General evaluation