SCORING SCHEME

The table below shows the conesponding points for each of the areas of the
clinical workbook.

Item Points
GOSO 10
Plan of Activities 10
Patient's Health Profile 20
Gordon's Functional Health Pattern
A. Health Perception - Health Management Pattern 20
B. Nutritional- Metabolic Pattern 20
C. Elimination Patter 20
D. Activity
- Exercise Pattem 20
E. Cognitive - Perceptual Pattern 20
F. Sleep - Rest Pattern 20
G. Self - Perception Pattern 20
H. Role - Relationship Pattern 20
l. Sexuality - Reproductive Pattem 20
J. Coping - Stress Tolerance Pattern 20
K. Value - Beliefs Pattern 20
Physical Domain
i. Brief Pain lnventory - Short Form 1 5
ii. Mini Nutritional Assessment 1 5
iii. Braden Scale 1 5
iv. Pathophysiology 20
Functional Domain
i. The Barthel lndex 1 5
ii. Lawton-Brody lnstrumentalActivities of Daily Living Scale 1 5
Psychological Domain
i. Mini-MentalStateExamination 1 5
ii. VAMC SLUMS Examination 1 5
iii. Patient Health Questionnaire (PHQ - 9) 1 5
Social Domain
i. Enrichd Social Support System (ESSI)
5
ii. Camberwell Assessment of Need Short Appraisal $chedule 1

1 5
(cANSAS)
Spiritual Domain

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 i. Hope Approach to SpiritualAssessment 15
ii. Spiritual Distress Assessment Tool (SDAT) 15
Diagnostic, Laboratory Procedures and Nursing Responsibilities 20
Medical Management and Nursing Responsibilities
i. Pharmacotherapy & NR 30
Diet, Activity Management & Nursing Responsibilities 10
Summary of Monitoring Sheet 2A
Nursing Care Plan
A1. PhysicalDomain 10
Flz. Physical Domain 10
43. Physical Domain 10
81. Functional Domain 't0
B.2. Functional Domain 10
83. Functional Domain 10
C1. Psychological Domain 10
C2. Psychological Domain 10
C3. PsychologicalDomain 10
D1. Social Domain 10
D2. Social Domain
D2. Social Domain
E1. Spiritual Domain
E2. Spiritual Domain
E2. Spiritual Domain
Therapy 50
Program of Activities 50
Therapy Evaluation 100
Nurses Notes 20
Evidence - Based Nursing Research (Reflection Paper) 10
Learning Feedback Diary 10

TOTAL BY WEEK

Formula in getting the percentage of the students' earned points:

Total Earned Points

Overall Potnts
x LOOo/a = Percentage Grade of the Stud.ent

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 Worksheet 1

Item Max Points

GOSO 10

Plan of Activities 10

Patient's Health Profile 20

Gordon's Functional Health Pattern
A. Perception - Health Management Pattern 20
B. Nutritional- Metabolic Pattern 20
C. Elimination Patter 20
D. Activity - Exercise Pattern 20
E. Cognitive - Perceptual Pattern 20
F. Sleep - Rest Pattern 20
G. Self - Perception Pattern 20
H. Role - Relationship Pattern 2A

l. Sexuality - Reproductive Pattern 20

J. Coping - Stress Tolerance Pattern 20
K. Value - Beliefs Pattern 20
Learning Feedback Diary 10

TOTAL 270

Hospita l/Faci ity Rotation

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Date and Shift

Clinical lnstructor

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 GENERAL OBJECTTVES AND SpECtFtC OBEJECTTVE (GOSO)
HRN: Date:
Clinical lnstructor: Area:

GENERAL OBJECTIVE
1ST DAY 2ND DAY

SPECTFIC OBJECTIVES

1ST DAY 2ND DAY

KNOWLEDGE
1 1

2 2

SKILLS
1 1

2 2

ATTITUDE
1 1

2 2

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r
 PLAN OF ACTIVITIES
Time lsr Day Time 2ND Day

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 PATIENT'S HEALTH PROFILE
lnstructions: Kindly fill out the information below through interview of the patient or
with the social worker. Be sure to write it legibly and accurately. Use proper code
names for privacy and confidentialitv of all involved.

l. Biographical Data

HRN:
Code Name:
Address
Contact Number:
Age
Birth Date:
Birth Place:
Gender:
Race
Ethnicity:
Nationality:
Religious Affiliation
Marital Status:
Number of Dependents:
Highest Ed ucational Attainment:
Occupation:
Source cf H istory/Reliability:
Referral:
Advance Directives/Living Will:
Primary Healthcare Provider:
Date &Time of Admission:
Attending Physician:
Medical Diagnosis:

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 ll. Client's History

A. General Health Status:

Vital Signs:

BP:_ mmHg Temp:_'C RR:_cpm PR:-bpm

A2 sal_a/a Ht:_cm Wt:_kg GCS:

B. Chief Complaints

C. History of Present lllness

lVofe; Share the history of your patient's history of present illness thoroughly in
your own words. Do not just copy what is written in the chart. Furthermore,
when taking the patient's history of present health concerns, be sure to explore
the symptoms comprehensively. The mnemonic *COLDSPA" and "PQRST,'
are a helpful guide to analyze a patient's symptoms.

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D. Past Medical History

a. Childhaod lllnessles

[]Allergies [ ] Childhood disease []Asthma [] Chicken pox

[]Measles []Mumps [] Tonsillitis [ ] Rubella
[] Others.

b. Hospitalization

Name of Hospital Date of Hospitalization Reason for Hospitalization

c. Previous Surgeries

Type and Date of Surgery Diagnosis Attending Physician

d. Ser'ous lnjuries

Type of Injuies When it happened? Reason for this injury/ies?

e. Se ri o u s/C h ra n i c //lnesses

\tVhen was the Where was the patient \Mro diagnosed

Illnessles
patient diagnosed? diagnosed? the patient?

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 f. lmmunizations

Immunization received How many \Mren is that Where was the

doses? dose/last dose immunization?
received?

g. Allergies

Foods Medications

h. tr/l ai ntenance Medications

Name of Drug &

Dose Timing Route
Preparation

Ex. Losartan S2mg/tab 1 tab OD po

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i. Recent Travel

Where? \lVtren? How many days? Reason for travel

E. Family Health History (Write in Narrative form):

PATERNAL HISTORY

MATERNAL HISTORY

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 GORDON'S FUNCTIONAL HEALTH PATTERN

Note: Completely fill out the different health patterns in a narrative format. Do
relevant comparison of the status of your patient and write your findings in the
lnterpretation part. Find valid references for your Analysis based on your
findings.

A. HEALTH PERCEPTION . HEALTH MANAGEMENT PATTERN

Before H ospitaliz atio n

D u ri ng H ospita lization

lnterpretation

Analysis

References.

Page 122
 B. NUTRITIONAL. METABOLIC PATTERN
Befo re H os pitalizatia n

D u ri ng H os pitalizatio n

lnterpretation

Analysis

References:

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