The care plan is a written document (either electronic or paper-based) that is used and altered constantly throughout the day. It’s based on a ‘template’ which defines the areas the care plan covers. Some templates are very simple and focus on the essentials of care – nutrition, mobility, sleeping, positioning, oral care and personal hygiene, for instance – while others can be very detailed and might include sections on issues like falls prevention, psychological needs, recording of clinical signs, communication and information.
1. 1
HISTORY COLLECTION
PATIENT PROFILE
I. History Collection:
Name :
Age :
Sex :
Education :
Occupation :
Religion :
Marital Status :
Husband’s Name :
Wife’s Name :
Address :
Date of Admission :
Diagnosis :
Ward Name :
I.P. No :
Bed No. :
II. Chief complaints :
III. History of Health status:
(a) Present Medical History :
(b) Past Medical History :
(c) Present Surgical History :
(d) Past Surgical History :
2. 2
IV. Family History :
(a) Family Tree :
S.
No
Name of family
Member
Age Sex Relationship Occupation
Health
status
Remarks
V. Personal History :
(a) Habits :
(b) Sleep :
(c) Nutrition :
(d) Elimination Pattern :
VI. Socio Economic Status :
(a) Housing :
(b) Ventilation :
(c) Electricity :
(d) Water supply :
3. 3
PHYSICAL ASSESSMENT/EXAMINATION
Vital signs:
Temperature :
Pulse :
Resp. Rate :
B.P. :
General Appearance :
Nourishment :
Body build :
Health :
Activity :
Consciousness :
Look :
Body curves :
Movement :
Height :
Weight :
Skin :
Colour :
Texture :
Temperature :
Lesions :
Rashes :
Lumps :
Itching :
Dryness :
Moles :
Head :
Size :
Shape :
Hair & Scalp/ Skull/ face :
Colour :
Distribution :
Hair loss :
Dandruff :
Lice :
Healthy :
11. 11
INTAKE AND OUTPUT RECORD
Name: Hospital No. Age: Sex:
Date Time Oral
Fluids
Naso
Gastric
Intra
Venous
Other
Routs
Total Urine Vomitys Aspirations Other Total