DRUG STUDY

Brand Name: _________________________________________ Generic Name: _____________________________ Pharmacologic Classification: ___________________________________

Dosage, Route & Frequency Drug-Drug & Drug- Side Effects Adverse Reactions
Drug Action Indications Contraindications
Recommended Prescribed Food Interactions (By System) (By System)

Responsibilities in the Nursing Process (ADPIE) Responsibilities in the Nursing Process (ADPIE)

References:____________________________________________________________________
 OBSTETRICAL HISTORY

Patient’s Name: ____________________ Age: ________ Date Admitted: ______________

Date and Time of Delivery: _____________________________________________________
Diagnosis: __________________________________________________________________

LMP: __________________ EDC: ___________________ AOG: ___________________

FH: ___________________ FHT: ___________________

OB SCORE:
G (gravida) = ____________ A (abortion) = ___________
T (term) = ____________ L (living) = _____________
P (premature)= ____________

Place of Manner of
Gravida AOG Presentation Complications
Confinement Delivery
G1

G2

G3

G4

G5
 SOAPIE CHARTING
(Subjective-Objective-Analysis-Plan-Intervention-Evaluation)

Age: _______ Sex: ________ CC: ___________________________________________________________________

Medical Diagnosis: _________________________________________________________________________________

DATE, TIME, AND PROGRESS NOTES

SHIFT

S-

O-

A-

P-

I-

E-

Patient’s Name / Room No. | 1

 FDAR CHARTING
(Focus-Data-Action-Response)

Age: _______ Sex: ________ CC: ___________________________________________________________________

Medical Diagnosis: _________________________________________________________________________________

Date, Time, and FOCUS PROGRESS NOTES

Shift
D-

A-

R-

Patient’s Name / Room No. | 2

 Mindanao State University – Iligan Institute of Technology Level: _________________________ Group:___________
COLLEGE OF NURSING Clinical Instructor: _________________
Assigned Area: ____________________

Name of Patient Assigned Student Vital Signs (10 AM) Vital Signs (2PM) Intake Output

T PR RR BP T PR RR BP IVF PO Others Urine Stool Others

ANATOMY AND PHYSIOLOGY

Patient’s Name / Room No. | 1

Patient’s Name / Room No. | 2
 Mindanao State University
Iligan Institute of Technology
COLLEGE OF NURSING
LEVEL II 1st SEM 2022-2023
NSG 123.5 & NSG 121.2

W L
K
DATES A B C D E F G H I J K

Aug 17-19,
2022
1
ENROLME
NT

Aug 22-28, (1,2) DR (1,2) DR (1,2) DR (1,2) DR (1,2) DR (1,2) DR (1,2) DR (1,2) DR (1,2) DR (1,2) DR (1,2) DR (1,2) DR
2022 SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION
2 MED, Surg, 7-11 7-11 7-11 7-11 7-11 7-11 7-11 7-11 7-11 7-11 7-11 7-11
OB, MED Aug. 26 Aug. 26 Aug. 27 Aug. 27 Aug. 26 Aug. 27 Aug. 27 Aug. 26 Aug. 26 Aug. 26 Aug. 26 Aug. 26
Ward BUTALID MAMAUAG MAMAUAG BUTALID GOMEZ GOMEZ MADJUS ORIAS POBLETE SANTILLANA MADJUS PADOGDOG

Aug 29- Sept

(3,4) DR (3,4) DR (3,4) DR (3,4) DR (3,4) DR (3,4) DR (3,4) DR (3,4) DR (3,4) DR (3,4) DR (3,4) DR (3,4) DR
4 2022
SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION
MED, Surg,
3 7-11 7-11 7-11 7-11 7-11 7-11 7-11 7-11 7-11 7-11 7-11 7-11
OB, MED
SEP. 2 SEP. 2 SEP. 3 SEP. 3 SEP. 2 SEP. 3 SEP. 3 SEP. 2 SEP. 2 SEP. 2 SEP. 2 SEP. 2
Ward
BUTALID MAMAUAG MAMAUAG BUTALID GOMEZ GOMEZ MADJUS ORIAS POBLETE SANTILLANA MADJUS PADOGDOG
(1) OB ORIENT (1) OB ORIENT (1) OB ORIENT (1) OB ORIENT (1) OB ORIENT (1) OB ORIENT (1) OB ORIENT (1) OB ORIENT (1) OB ORIENT (1) OB ORIENT (1) OB ORIENT (1) OB ORIENT
SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9
7-3 7-3 7-3 7-3 7-3 7-3 7-3 3-11 7-3 7-3 7-3 7-3
SABDANI MAYBITUIN GOMEZ BUTALID ORIAS PALER ORTEGA, D. RAMEL, R. VELOSO LEC 3 CLARET LEC 1
(1) PED (1) PED (1) PED
(1) PED ORIENT (1) PED ORIENT (1) PED ORIENT (1) PED ORIENT (1) PED ORIENT (1) PED ORIENT (1) PED ORIENT (1) PED ORIENT (1) PED ORIENT
Sept 5-11, ORIENT ORIENT ORIENT
SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9
2022 SEP. 9 SEP. 9 SEP. 9
4 3-11 3-11 3-11 3-11 3-11 3-11 3-11 3-11 3-11
DR/NICU/WA 3-11 3-11 3-11
SABDANI GOMEZ BUTALID ORIAS ESCABARTE ORTEGA, D. RAMEL, Q. VELOSO LEC 3
RD MAYBITUIN CLARET LEC 1
(1) CHN (1) CHN (1) CHN
(1) CHN ORIENT (1) CHN ORIENT (1) CHN ORIENT (1) CHN ORIENT (1) CHN ORIENT (1) CHN ORIENT (1) CHN ORIENT (1) CHN ORIENT (1) CHN ORIENT
ORIENT ORIENT ORIENT
SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9 SEP. 9
SEP. 9 SEP. 9 SEP. 9
3-11 3-11 3-11 3-11 7-3 3-11 3-11 7-3 3-11
3-11 7-3 11PM-7AM
MARTIN NEBRES BUTALID ORTEGA, C. RAMEL, R. TABIL RAMEL, Q. MANGARUN GAYAO
RIDAD SANTILLANA MARANDA
(2) OB (2) OB (2) OB (2) OB (2) OB (2) OB (2) OB (2) OB (2) OB (2) OB (2) OB (2) OB
SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION
SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17
Sept 12-18, 7-3 7-3 7-3 7-3 7-3 7-3 7-3 7-3 7-3 7-3 7-3 7-3
2022 SABDANI MAYBITUIN GOMEZ BUTALID ORIAS PALER ORTEGA, D. COYOCA VELOSO LEC 3 CLARET LEC 1
5
DR/NICU/ (2) PED (2) PED (2) PED (2) PED (2) PED (2) PED (2) PED (2) PED (2) PED (2) PED (2) PED (2) PED
WARD SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION SIMULATION
SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17 SEP. 17
3-11 3-11 3-11 3-11 3-11 3-11 3-11 3-11 3-11 3-11 3-11 3-11
SABDANI MAYBITUIN GOMEZ BUTALID ORIAS PALER ORTEGA, D. COYOCA VELOSO LEC 3 CLARET LEC 1

Page 1 of 5
 Mindanao State University
Iligan Institute of Technology
COLLEGE OF NURSING
LEVEL II 1st SEM 2022-2023
NSG 123.5 & NSG 121.2

Sept 19-25,
2022
DR/NICU/ (5,6) DR/NICU (3,4) OB (3,4) OB (3,4) PED (3,4) PED (3,4) PED (3,4) PED (5,6) DR/NICU (5,6) DR/NICU (5,6) DR (5,6,) DR
WARD Sept. 23-24 SEP. 24-25 SEP. 24-25 SEP. 23-24 SEP. 23-24 SEP. 23-24 SEP. 23-24 Sept. 23-24 Sept. 23-24 Sept. 23-24 Sept. 25
3-11 3-11 3-11 7-3 7-3 3-11 3-11 7-3 7-3 3-11 7-11
PADOGDOG SABDANI RAMEL, Q. ORIAS PALER ORTEGA, D. LEC 1 POBLETE SANTILLANA MADJUS ORIAS

W L
K
DATES A B C D E F G H I J K
(2) CHN (2) CHN (2) CHN (2) CHN (2) CHN (2) CHN (2) CHN (2) CHN (2) CHN (2) CHN (2) CHN (2) CHN
SEP. 30 SEP. 30 SEP. 30 SEP. 30 SEP. 30 SEP. 30 SEP. 30 SEP. 30 SEP. 30 SEP. 30 SEP. 30 SEP. 30
Sept 26-Oct 2 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5
, 3022
MARTIN GOMEZ NEBRES BUTALID ORTEGA, C. CLARET TABIL RAMEL, Q. VELOSO GAYAO SANTILLANA SABDANI
7 DR/NICU/
WARD (7,8) DR/NICU (5,6) OB (5,6) OB (5,6) PED (5,6) PED (5,6) PED (5,6) PED (7,8) DR/NICU (7,8) DR/NICU (7,8) DR/NICU (3,4) OB
Oct 1 - 2 OCT. 1-2 OCT.1-2 OCT.1-2 OCT.1-2 OCT.1-2 OCT.1-2 Oct 1 - 2 Oct 1 - 2 Oct 1 - 2 OCT. 1-2
3-11 3-11 3-11 7-3 7-3 3-11 3-11 7-3 7-3 3-11 7-3
ORIAS SABDANI LEC 2 CLARET PALER ORTEGA, D. COYOCA POBLETE SANTILLANA MADJUS LEC 2
(3) CHN (3) CHN (3) CHN (3) CHN (3) CHN (3) CHN (3) CHN (3) CHN (3) CHN (3) CHN (3) CHN (3) CHN
OCT. 7 OCT. 7 OCT. 7 OCT. 7 OCT. 7 OCT. 7 OCT. 7 OCT. 7 OCT. 7 OCT. 7 OCT. 7 OCT. 7
8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5
Oct 3-9, 3022
MARTIN GOMEZ NEBRES BUTALID ORTEGA, C. CLARET TABIL RAMEL, Q. VELOSO GAYAO SANTILLANA SABDANI
DR/NICU/
8 (5,6,7) DR/NICU (8,9) DR/NICU
WARD (3,4) PED (3,4) PED (3,4) PED (3,4) PED (3,4) OB (3,4) OB (9,10) DR/NICU (9,10) DR/NICU (5,6) OB
AMC AMC
OCT. 8-9 OCT. 8-9 OCT. 8-9 OCT. 8-9 OCT. 8-9 OCT. 8-9 Oct. 8 - 9 Oct. 8 - 9 OCT. 8-9
OCT. 7 & 9 OCT. 8
7-3 7-3 3-11 3-11 7-3 3-11 7-3 3-11 7-3
7AM-7PM 7PM-7AM
SABDANI MAYBITUIN LEC 3 CLARET ORIAS LIWAGON BALILI
COYOCA POBLETE MADJUS LEC 1
(4) CHN (4) CHN (4) CHN (4) CHN (4) CHN (4) CHN (5) CHN (4) CHN (4) CHN (4) CHN
OCT. 14 OCT. 14 OCT. 14 OCT. 14 OCT. 14 OCT. 14 OCT. 14 OCT. 14 OCT. 14 OCT. 14
Oct 10-16, 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5
(4) CHN (4) CHN
3022 MARTIN GOMEZ NEBRES BUTALID ORTEGA, C. CLARET TABIL RAMEL, Q. OCT. 14 OCT. 14
SANTILLANA SABDANI
9 DR/NICU/ (8,9) DR/NICU (5,6,7) DR/NICU (9,10)
(5,6) PED (5,6) PED (5,6) PED (5,6) PED (5,6) OB (5,6) OB 8-5 8-5
WARD AMC AMC DR/NICU
OCT. 15-16 OCT. 15-16 OCT. 15-16 OCT. 15-16 OCT. 15-16 OCT. 15-16 VELOSO GAYAO
OCT. 15 OCT. 14 & 16 Oct 15-16
7-3 7-3 3-11 3-11 7-3 3-11
7PM-7AM 7-7 7-3
SABDANI MAYBITUIN LEC 3 CLARET ORIAS BALILI BALILI
COYOCA MADJUS

Page 2 of 5
 Mindanao State University
Iligan Institute of Technology
COLLEGE OF NURSING
LEVEL II 1st SEM 2022-2023
NSG 123.5 & NSG 121.2

(5) CHN (5) CHN (5) CHN (5) CHN (5) CHN (5) CHN (5) CHN (5) CHN (5) CHN (5) CHN (5) CHN (5) CHN
Oct 17-23,
OCT. 21 OCT. 21 OCT. 21 OCT. 21 OCT. 21 OCT. 21 OCT. 21 OCT. 21 OCT. 21 OCT. 21 OCT. 21 OCT. 21
10 3022 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5
MARTIN GOMEZ NEBRES BUTALID ORTEGA, C. CLARET TABIL RAMEL, Q. VELOSO GAYAO SANTILLANA SABDANI

Oct 24-30,
3021 (6) CHN (6) CHN (6) CHN (6) CHN (6) CHN (6) CHN (6) CHN (6) CHN (6) CHN (6) CHN (6) CHN (6) CHN
(PALAKASAN OCT. 28 OCT. 28 OCT. 28 OCT. 28 OCT. 28 OCT. 28 OCT. 28 OCT. 28 OCT. 28 OCT. 28 OCT. 28 OCT. 28
11
Oct 27-31, 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5 8-5
3022) MARTIN GOMEZ NEBRES BUTALID ORTEGA, C. CLARET TABIL RAMEL, Q. VELOSO GAYAO SANTILLANA SABDANI
W L
K
DATES A B C D E F G H I J K
(7,8) DR/NICU
AMC
(5,6,7) (5,6,7) DR/NICU (5,6) DR/NICU NOV. 5-6
Oct 31-Nov 6, (5,6,7) DR/NICU (3,4) OB (3,4) OB
DR/NICU AMC AMC 7-3
3022 NOV. 3-5 NOV. 5-6 NOV. 5-6
12 NOV. 3-5 NOV. 4 & 5 NOV. 5 ORTEGA, C.
DR/NICU, 3-11 3-11 7-3
7-3 7-7 7pm-7am (3,4) OB (3,4) OB
OR/ER/OPD
PADOGDOG
ORIAS
LIWAGON AMARILLO
LEC 2 LEC 1 NOV. 5-6 NOV. 5-6
7-3 3-11
LEC 3 CLARET
(10) DR/NICU
AMC
NOV. 12
Nov 7-13, (8,9,10) (8,9,10) DR/NICU
(9,10) DR/NICU 7PM-7AM (3,4) OB (5,6) OB (5,6) OB (5,6) OB
3022 DR/NICU AMC
NOV. 11-12 BALILI NOV. 12-13 NOV. 12-13 NOV. 12-13 NOV. 12-13
13 DR/NICU, NOV. 11-13 NOV. 11 & 13
7-3 3-11 7-3 7-3 3-11
OR/ER/OPD 3-11 7-7 (6) OB
MADJUS
PADOGDOG LIWAGON NOV. 11
ORTEGA, D. VELOSO LEC 3 CLARET
7-3
LEC 2
(8,9.5) DR/NICU
AMC
(3,4) OB NOV. 18
Nov 14-20,
NOV.18-19 (3,4) OB 7-7 (7) DR/NICU AMC (3,4) PED (3,4) PED (3,4) PED (3,4) PED
3022
7-3 NOV. 18-19 BALILI NOV. 19 NOV. 19-20 NOV. 19-20 NOV. 19-20 NOV. 19-20
14 OR/ER/OPD,
3-11 (9.5,10) DR/NICU 7pm-7am 3-11 7-3 7-3 3-11
WARD SABDANI
MAYBITUIN AMC AMARILLO VELOSO LEC 3 CLARET LEC 1
NOV. 20
7-7
LIWAGON

Page 3 of 5
 Mindanao State University
Iligan Institute of Technology
COLLEGE OF NURSING
LEVEL II 1st SEM 2022-2023
NSG 123.5 & NSG 121.2

Nov 21-27,
(8,9,10) DR/NICU (10) DR/NICU
3021 (5,6) OB (5,6) OB (6) OB (5,6) PED (5,6) PED (5,6) PED (5,6) PED
AMC AMC
OR/ER/OPD, NOV. 25-26 NOV. 25-26 NOV. 27 NOV. 26-27 NOV. 26-27 NOV. 26-27 NOV. 26-27
15 Nov.25 & 27 NOV. 26
WARD 3-11 3-11 7-3 3-11 7-3 7-3 3-11
7-7 7PM-7AM
SABDANI MAYBITUIN AMARILLO
PALER BALILI
LEC 2 LEC 3 CLARET LEC 1

(11,12) DR/NICU
(11,12) ONLINE (11,12)
(11,12) DR/NICU (11,12) DR/NICU (5,6,7) DR/NICU (11,12) DR/NICU (11,12) DR/NICU
Nov 28-Dec 4, DR/NICU Dec. 2 & 4 (5,6) OB DR/NICU
ONLINE ONLINE AMC ONLINE ONLINE
3022 ONLINE 7-3 DEC, 2 & 4 ONLINE
16 Dec. 2 & 4 Dec. 2 & 4 DEC. 2 & 4 Dec. 3-4 Dec. 3-4
OR/ER/OPD Dec. 3-4 BALILI 7-3 Dec. 3-4
7-3 7-3 7-7 7-3 7-3
7-3 ORTEGA, D. 3-11
ORIAS AMARILLO LIWAGON POBLETE MADJUS
PADOGDOG MADJUS

W
K
DATES A B C D E F G H I J K
(9,10)
DR/NICU
DEC. 9-10
7-3
(11,12)
(11,12) DR/NICU (11,12) DR/NICU (8,9,10) DR/NICU POBLETE
Dec 5-11, DR/NICU
ONLINE ONLINE AMC
3021 ONLINE
17 Dec. 10 & 12 Dec. 10 & 12 DEC. 9 & 11 (11,12)
OR/ER/OPD Dec. 10-11
7-3 7-3 7-7 DR/NICU
7-3
LIWAGON BALILI AMARILLO ONLINE
MADJUS
DEC. 11
7-11
POBLETE

Dec 12-18,
3021 (11,12) DR/NICU
OR,ER/OPD ONLINE
18 DR/NICU DEC. 16
X-MAS 7-11
BREAK (Dec 17- LIWAGON
Jan 1, 3030)

Dec 19-25,
3021
19 OR,ER/OPD
DR/NICU

Dec 26-Jan 1,
3030
30 OR,ER/OPD
DR/NICU

Page 4 of 5
 Mindanao State University
Iligan Institute of Technology
COLLEGE OF NURSING
LEVEL II 1st SEM 2022-2023
NSG 123.5 & NSG 121.2

Jan 2-8, 3030

21 Final Exam
Week

Jan 9-15,
22 2022

Prepared by: Noted by:

Rambe C. Ramel, Jr., MAN, RN Dr. Abdullah Junior S. Mangarun, MAN, MN, RN
Clinical Coordinator Dean

Page 5 of 5
 NURSING CARE PLAN
Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

Patient’s Name / Room No. | 1

 NURSING CARE PLAN
Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

Patient’s Name / Room No. | 2

 NURSING CARE PLAN
Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

Patient’s Name / Room No. | 3

 NURSING CARE PLAN
Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

Patient’s Name / Room No. | 4

 NURSING CARE PLAN
Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

Patient’s Name / Room No. | 5

 NURSING CARE PLAN
Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

Patient’s Name / Room No. | 6

 NURSING CARE PLAN
Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

Patient’s Name / Room No. | 7

 NURSING CARE PLAN
Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

Patient’s Name / Room No. | 8

 NURSING CARE PLAN
Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

Patient’s Name / Room No. | 9

 NURSING CARE PLAN
Identified Problem:

Nursing Diagnosis:

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:

Objective:

Long term objectives:

Long term:

Patient’s Name / Room No. | 10

Patient’s Name / Room No. | 11
 MSU-Iligan Institute of Technology _DF-002
August 2016
College of Nursing
PN-1/Ward
NURSING HEALTH ASSESSMENT I

Student Name: __________________________________ Date/s of Care: _______________ Score: _________

Area of Assignment: __________________________ Clinical Instructor: ________________________________

DEMOGRAPHIC DATA

Name: ________________________________________ Age: _________ Sex: __________ Status: _________

Address: ______________________________________ Religion: __________ Occupation: ________________

HEALTH HISTORY
A. Chief Complaint/s:

B. Impression/Admitting Diagnosis:

C. History of Present Illness: (Location, onset, character, intensity, duration, aggravation and alleviation, associated
symptoms, previous treatment and result, social and vocational responsibilities)

D. History of Past Illness/es: (Previous hospitalization, injuries, procedures, infectious disease, immunization/ health
maintenance, major illness, allergies, medication, habits, birth and development history, nutrition – for pedia)

E. Health Habits
Kind Frequency Amount Period
1. Tobacco
2. Alcohol
3. OTC drugs

F. Family History with Genogram

rd
History of Heredo-familial diseases: Genogram (up to 3 generation)
____ Cancer Legend:
____ DM
____ Asthma
____ Hypertension
____ Cardiac Disease
____ Mental Disorder
____ Others: _____________

G. Patient’s Perception
Present Illness:

Hospital Environment:

H. Summary of Interaction

Patient’s Name / Room No. | 1

 PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

Date: ______________

Vital Signs:
Temp: _________ RR: __________ Weight: ______________
PR: __________ BP: __________ Height: ______________

Observation: _______________________________________________________________________________________

1. General (weight loss or gain; fever,

chills, night sweats; mood; stage of
development, race, sex; signs of
distress; position; cooperative or not;
state if irritable, agitated or pleasant;
etc.)

2. Head (headache, injury,

tenderness, etc.); Eyes (change in
visual fields, glasses, blurring,
diplopia, pain, loss of vision, tearing,
dry eyes, etc.); Ears (change in
hearing, tinnitus, discharge, dizziness,
etc.); Nose (allergies, sinus problem,
obstruction, polyps, sneezing,
epistaxis, etc.);Throat (toothaches,
loose teeth, bleeding gums, mouth
sores, hoarseness, difficulty
swallowing, etc.)
3. Integumentary System

4. Respiratory System
(chest pain, dyspnea, cough, amount
and color of sputum, hemoptysis, etc.)

5.Cardiovascular System (chest

pain/ pressure/ tightness, palpitations,
orthopnea, paroxysmal nocturnal
dyspnea, shorntness of breath,
Patient’s Name / Room No. | 1
edema, claudication, endurance, etc.)

6. Digestive System
(dysphagia, heartburn, ulcer, GERD,
indigestion, food intolerance, diarrhea,
constipation, abdominal pain, blood in
stool, black tarry stools, changes in
bowel habits, reduced caliber of
stools, hemorrhoids, etc.)
7. Excretory System
(urgency, frequency, nocturia, dysuria,
hematuria, recurrent UTIs, STD,
incontinence, etc.)

8.Musculoskeletal System (limitation

in movement, stiffness, joint pain,
swelling or redness, arthritis, muscle
spasms, muscle weakness, etc.)

9. Nervous System

10. Endocrine System

(heat/cold intolerance, weight change,
fatigue, polydepsia, polyuria,
polyphagia, changes in hair
distribution, etc.)
11. Reproductive System

Patient’s Name / Room No. | 2