ANGELES UNIVERSITY FOUNDATION

COLLEGE OF NURSING

NURSING CARE MANAGEMENT 107 - RLE

Nursing Care Rendered Format

I. PERSONAL DATA:
Name of Patient: Gender:

Civil Status: Birthdate:

Address: Age:

Date & Time of Admission:

II. HISTORY:
A. Chief Complaint:

B. Brief History:

History of Present Illness or Recent Health Concern (COLDSPA)

Character:

Onset:

Location:

Duration:

Severity (on a scale of 1-10):

Pattern:

Associated factors:

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 Past Health History

Family Health History

Lifestyle and Health Practice Profile

Description of Typical Day:

Nutrition and Weight Management:

Activity Level and Exercise:

Sleep and Rest:

Substance Abuse (if applicable):

Self-Concept and Self-Care Responsibilities:

Social Activities:

Relationships:

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 Values and Belief System:

Education and Work:

Stress Level and Coping Styles:

Environment:

III. ASSESSMENT:
A. Vital Signs:

Blood pressure:

Oxygen saturation:

Pulse rate:

B. Review of Systems

Skin, hair, nails:

Head and neck:

Eyes:

Ears:

Mouth, throat, nose, and sinuses:

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 Thorax and lungs:

Breast and regional lymphatics:

Heart and neck vessels:

Peripheral vascular:

Abdomen:

Female genitalia:

Anus, rectum, and prostate:

Musculoskeletal:

Neurologic:

IV. MANAGEMENT:

LIST OF
DATE AND TIME TYPE OF
MANAGEMENT DESCRIPTION RATIONALE
PERFORMED INTERVENTION
RENDERED

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AUF-Form-CON-RLE-23
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