NURSING HISTORY (DAY 1)

A. Chief Complaints/ Reason for Visit

B. History of Present Illness (Narrative)

a. Location

b. Character/Quality

c. Timing/ Chronology (Onset, Duration, Frequency)

d. Setting

e. Aggravating/ Relieving Factors

f. Associated Signs and Symptoms

g. Initial Management at Home

h. Initial Check-up/Medication

i. Client’s Perception

C. History of Past Illness (Narrative)

a. Allergies- food, drug, environmental factors, any substances

b. Childhood Illness- measles, mumps etc.

 c. Surgeries- type, date, name of hospital, recovery period

d. Past Hospitalizations-cause, name of hospital, treatment, duration of stay, name of physician

e. Serious/Chronic Illnesses-DM, HTN, CA etc.

f. Accidents/Injuries-accidents, fractures, wounds, burns

g. Immunizations-measles, DPT, Hepa B, OPV, BCG, tetanus, note the date of last immunization

h. Last Examinations-physical exam, vision, hearing, ECG, C-Xray

For women: Pap smear, mammogram

i. Obstetric History (Women)- number of pregnancies ( gravidity), number of births (parity), number of
abortions and miscarriages, type of delivery (vaginal or cesarean section), postpartum care

j. Current Medications- prescription and over-the-counter medications such as vitamins, birth control pills,
aspirin, antacids. For each medication, give the name, dose and schedule, duration of medication
 PEROS (Physical Assessment and Review of Systems)
(DAY 1)
Note: Assessment should follow IPPA / IAPP fashion if applicable. This serves as guide in performing
assessment thoroughly.
In writing your PEROS requirement, please draw your own table following this format in a clean
sheet of long bond paper so that you can utilize more space for your assessment findings.

Areas Assessed Subjective Objective Findings Problem Identified

Findings
General Health
Survey

Integumentary
System
HEENT
a. Head and
face
b. Eyes
c. Ears
d. Nose
e. Oral Cavity
Neck
Respiratory
System

Cardio-vascular
System
Breast and axilla

Gastro-intestinal
System and the
abdomen
Genito-urinary /
Reproductive
system

Musculoskeletal
System
Neurologic
System
Lymphatic /
Hemato-logic
System
 ENDORSEMENT SHEET
DAY 1
PN Name: ________________________________________________________ Date: ______________
Section: ________________________ Group: _______________________ Area: ____________________

Bed # AM PM NOC
Patient’s Name:

Age:

Diagnosis/Impression/CC

Attending Physician/s

Vital Signs Temp: Temp: Temp:

CRT: CRT: CRT:
PR: PR: PR:
BP: BP: BP:
RR: RR: RR:
SpO2: SpO2: SpO2:
Significant Findings upon
Assessment:
Meds due next shift & Hold,
NPO status, no stock

Diet

Ongoing IVF

IVF to follow

Intake: (Oral, IV, OF, Meds

in large amount)
 Output:

IV left:

Nursing care rendered

Student Signature: ______________________

Clinical Instructor: _______________________

 TIME BUDGET (DAY 1)

DATE: TIME: ACTIVITIES:

 NURSE’S NOTES (DAY 1)

DATE: INFORMATION:
 NURSING CARE PLAN (ACTUAL)
DAY 1

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION