NEW PROFESSIONS TECHNICAL INSTITUTE 4000 West Flagler Street Miami, Florida 33134 (305) 461-2223 / Fax: (305) 461-3029 STUDENT NAME: CLIENT’S INITIALS: DATE: CLIENT’S AGE: Advance Directives: Restrains: Y / N Admitting Medical Diagnosis: Chief Complaint: History of Present illness: Past Medical History: Cultural and Spiritual Assessment: GENDER: M / F ALLERGIES: DIET (including tube feeding with rate) Medications taken at home or before transfer: (include dose and frequency) Summarize Pathophysiology (in our own words, include definition, etiology and physiology) Definition of Concurrent Diagnoses (all of them) Correlational of all diagnoses with current condition Signs and Symptoms: (Indicate which ones your client has) Diagnostic test for this condition: (Indicate which ones utilized for client) Treatment (med/surg/pharmacological) Nursing Interventions and rationale: Medications administered during client assignment including IVF’s, Rate, and reason for Fluids. Generic/Trade Name Classification Major Action Reason Prescribed to Client Dose Given/Normal Range Adverse Effects Precautions/Contraindications Nursing Implication . Generic/Trade Name Classification Major Action Reason Prescribed to Client Dose Given/ Normal Range Adverse Effects Precautions/Contraindications Nursing Implication Generic/Trade Name Classification Major Action Reason Prescribed to Client Dose Given/ Normal Range Adverse Effects Precautions/Contraindications Nursing Implication LABORATORY AND DIAGNOSTIC TESTS Other Pertinent labs DATE DIAGNOSTIC STUDY RESULTS SIGNIFICANCE TO PATIENT NURSING DIAGNOSIS R/T AND EVIDENCED BY- Subjective Supportive DataObjective Supportive Data NURSING ACTIONS SCIENTIFIC PRINCIPLE/ RATIONALE EVALUATION MODIFICATION NURSING DIAGNOSIS R/T AND EVIDENCED BY- Subjective Supportive DataObjective Supportive Data NURSING ACTIONS SCIENTIFIC PRINCIPLE/ RATIONALE EVALUATION MODIFICATION DISCHARGE PLANNING CLIENT’S NEED FOR DISCHARGE INTERVENTIONS RATIONALE 
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