History of Present Illness (HPI)
History of Present Illness (HPI)
Patient Information
(1)
Patient Initials:
Age & Gender:
Height/Weight:
Code Status:
Living Will/ DPOA:
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY GOT TO THE HOSPITAL- UNTIL NOW WHEN YOU ARE PROVIDING CARE? (USE SEPARATE ATTACHED WORD DOC WHEN NEEDED)
Medical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED MEDICAL PROBLEMS
Surgical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED SURGICAL PROBLEMS
Social History:
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
Chief Complaint
Admitting Diagnosis & Admission Date
Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage (based on objective assessment)
Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns: include the following Social Determinants of Health (SDOH)
❋Economic Stability ( MAY DELETE THESE ‘TIPS” TO USE SPACE)
❋ Education
❋Social and Community Context
❋ Health and Health Care
❋ Neighborhood and Built Environment
Concept Map (TEMPLATE)
Student Name:
Instructor:
DATE Care Provided and UNIT:
Key Diagnostic Tests/ Procedures and Lab Results with Dates and Normal Ranges (3)
Lab Tests
Normal Ranges
Admission Lab Values
Current Lab Values
Explain Abnormal Labs R/T Your Pt
INCLUDE: Appropriate Diagnostic Tests/ Procedures- DATEs and RESULTS
(Can add See attached Word Doc)
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE
EQUIPMENT ( MAY DELETE THESE ‘TIPS” TO USE SPACE)
MEDS
TREATMENT
REFERRALS NEEDED
Medical Management and Collaborative Plan
(from MD, PT, OT notes….etc.) *Consider past 24 – 48 hours
Patient Education (In Pt.) for Transfer/ Discharge Planning
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
Medications & Allergies (2)
Medication Name
Dose
Route
Freq.
Indications (PRN meds must include MD ordered Indication)
Mechanism of Action
Side Effects/
Adverse Reactions
Nursing Considerations
RN Considerations
Concept Map (TEMPLATE)
Student Name:
Instructor:
DATE Care Provided and UNIT:
Respiratory (7)
Cardiovascular (6)
Vital Signs (4)
Neurological (5)
ASSESSMENT/
REVIEW OF SYTEMS
Musculoskeletal
(8)
GI
Hydration/Nutrition (9)
GU (10)
Rest/ Exercise (11)
Integumentary (12)
Misc.
Psychosocial (14)
Endocrine (13)
Concept Map (TEMPLATE)
Student Name:
Instructor:
DATE of Care Provided and UNIT:
Priority Nursing Diagnosis #1
Priority Nursing Diagnosis #2
PLAN OF CARE
Evaluation #1
Intervention #1
At Risk Dx.-
Outcome/Goal #1
Outcome/Goal #1
At Risk Interventions
At Risk Outcomes/
Goal
Evaluation #2
At Risk Evaluation Plan
Interventions # 2
