GODAVARI COLLEGE OF NURSING, JALGAON

DAILY CLINICAL DAIRY REPORT

NAME OF THE PATIENT: AGE:

IPD NO-- WARD: SEX:
MARITAL STATUS: RELIGION: DIET:
DATE OF ADMISSION: EDUCATIONAL: OCCUPATION:
DIAGNOSIS:

VITAL SIGNS:

Temperature Pulse Respiration Blood pressure

1. LIST OF IDENTIFIED NEEDS:

2. ASSESSMENT:

SUBJECTIVE DATA:
OBJECTIVE DATA:

3. NURSING DIANOSIS:

4. EXPECTED OUTCOME:
5. PLANNING OF NURSING CARE:

6. NURSING CARE GIVEN:

7. EVALUATION:

8. NEW LEARNING:

SIGNATURE OF THE TEACHER. SIGNATURE OF THE CLINICAL INSTRUCTOR.

 GODAVARI COLLEGE OF NURSING, JALGAON
MONTLY REPORT CLINICAL POSTING

[To be submitted to class teacher at the end of the month]

1. Department{Area Of Posting]:
2. Bed Strength[ Including Unit distribution]
3. Registers Maintained In Ward.
4. Common diseases of the patient in the ward:
5. Major Equipments in the Ward with Uses.
6. Treatment Procedures[Medical And Surgical]:
7. Nursing Procedures With Respect To Area of Posting.
8. Your experience in your own words and advice for improvement.

SIGNATURE OF THE TEACHER. SIGNATURE OF THE CLINICAL INSTRUCTOR.

 SAMPLE.
DAILY CLINICAL DAIRY REPORT

DATE OF HEALTH HISTORY:

NAME OF THE PATIENT:

AGE: SEX: …………… IPD NUMBER: WARD: BED NO:

DATE OF ADMISSION: MERITAL STATUS: RELIGION:

DIET: EDUCATIONAL STATUS: OCCUPATION:

DIAGNOSIS:

TREATMENT UNDER DR:

LIST OF IDENTIFIED NEEDS: -

Fever, Pain, difficulty in breathing, Anxiety, loss of appetite………SINCE HOW MANY DAYS.

Ex-Fever since 3 days

ASSESSMENT:

SUBJECTIVE DATA: [Whatever the patient says- Ex- Patient verbalization of fever since
3 days

OBJECTIVE DATA: Thermometer reading- 38c..

NURSING DIANOSIS: [NANDA TERM [R/L] DISEASE CONDITION OR TREATMENT/ [As

evidenced By] Sign AND Symptoms.
EX- Acute Pain [NANDA TERM} related to disease condition as evidenced by patient
verbalization of pain {sign} and pain scale reading 5/10.

Acute Pain [NANDA TERM} related to INCISION ON…….as evidenced by patient verbalization
of pain {sign} and pain scale reading 5/10.

EXPECTED OUTCOME:

Ex-Patient will be free from fever or Patient will maintaion normal body temperature.

PLANNING OF NURSING CARE:

1. What you are going to do with respect to sign and symptoms, plan of activity must be
written in future tense.

NURSING CARE GIVEN:

Whatever the care that you have given to patients [ implementation of plan of
activity}

EVALUATION: Reassessment

NEW LEARNING: For Ex- Registers maintained in ward, Dressing trolley set up, O2 cylinder
use, Ventilator Monitor, Tracheostomy care, New procedure, ,BMW,Intracath sizes, IV fluid
contents, CSSD set Up,
Note- At the end of month – every student must submit allotted ward clinical duty experience
report- Name of the ward, cases that get admitted in ward, Procedures in ward, main
equipments in ward, registers maintained in ward and your own experience.

SIGNATURE OF THE TEACHER SIGNATURE OF THE CLINICAL INSTRUCTON.