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    Patient Database Nursing

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    nplooj_ski
    This document contains information about a patient's admission to care including their dates of care, admitting diagnosis, surgical procedures, past medical and surgical history, advance directives, pertinent laboratory and diagnostic test results, current treatments, abilities to perform activities of daily living independently or with assistance, current medications, allergies, and notes on patient education.

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    Patient Database Nursing

    Uploaded by

    nplooj_ski
    13 views2 pages
    This document contains information about a patient's admission to care including their dates of care, admitting diagnosis, surgical procedures, past medical and surgical history, advance directives, pertinent laboratory and diagnostic test results, current treatments, abilities to perform activities of daily living independently or with assistance, current medications, allergies, and notes on patient education.

    Original Description:

    Nursing patient database to help record data

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    This document contains information about a patient's admission to care including their dates of care, admitting diagnosis, surgical procedures, past medical and surgical history, advance directives, pertinent laboratory and diagnostic test results, current treatments, abilities to perform activities of daily living independently or with assistance, current medications, allergies, and notes on patient education.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    13 views2 pages

    Patient Database Nursing

    Uploaded by

    nplooj_ski
    This document contains information about a patient's admission to care including their dates of care, admitting diagnosis, surgical procedures, past medical and surgical history, advance directives, pertinent laboratory and diagnostic test results, current treatments, abilities to perform activities of daily living independently or with assistance, current medications, allergies, and notes on patient education.

    Copyright:

    © All Rights Reserved
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    Patient Database

    Student Name:

    ADMISSION INFORMATION
    Dates of Care:

    Pt. Initials:

    Reason for Seeking Care (pts own words)

    Age:

    Sex:

    Date of Admission

    Cultural Considerations:

    Admitting Diagnosis & Surgical Procedures This Admission

    Past Medical & Surgical History

    ADVANCE DIRECTIVES: Living Will: YES

    NO

    Healthcare POA: YES

    NO

    POLST: YES

    PERTINENT LABORATORY DATA


    Test

    Norms

    Admit

    Current

    Comments

    PERTINENT DIAGNOSTIC TESTS

    TREATMENTS

    ADLs
    Feeding: independent_______
    assistance_______

    needs

    Dressing: independent_______

    needs assistance______

    Toileting: independent______
    assistance_______

    needs

    Hygiene: independent_______

    needs assistance_______

    NO

    Patient Database, Continued


    Medications
    ALLERGIES:

    Medication/Classification

    Reason pt is on the
    medication

    Nursing Considerations

    Patient Education

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