NUR 2310 -- Client Information Sheet

SN Name: _____________________ Date: _______________

Client Room Number Physician

Admission Date: Past Medical History/Chronic Diseases

Admitting Dx:
Surgery Date/Procedure (if applicable)

Code Status: Allergies:

Cultural/Religious Influences Age:

Description of Client:

Vital Sign Ranges (over last 24-48 hrs)

Within last 48º Day of Care Significant health data (over past 24-48 hours; report
High Low High Low info, pertinent lab data, etc.)

BP

HR

Resp

Temp
All Current Orders: Do not list meds. Refer to MDs’
orders & treatment records.

Generic Name Trade Name Drug Class Use Dose Route Freq

Generic Name Trade Name Drug Class Use Dose Route Freq

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 NUR 2310 -- Client Information Sheet

Most Recent Lab / Diagnostic Test Results (Include other info on reverse)
Date Name of Test Client Data Normal Ranges Significance of Abnormal Values

Definition/ Expected Manifested Potential Complications

Pathophysiology S/S S/S

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 NUR 2310 -- Client Information Sheet

Ns Dx #1:
Intervention #1
Intervention #2
Intervention #3
Ns Dx #2:
Intervention #1
Intervention #2
Intervention #3
Ns Dx #3:
Intervention #1
Intervention #2
Intervention #3
Ns Dx #4:
Intervention #1
Intervention #2
Intervention #3
Ns Dx #5:
Intervention #1
Intervention #2
Intervention #3

Fall 2009 Page 3