Running head: NAME OF CARE PLAN 1
Title of Plan of Care
Name
South University Online
Faculty Name
NSG 6001
Date
NAME PLAN OF CARE 2
**Please delete this statement and anything in italics prior to submission to shorten the length
of your paper.
Patient Initials ______
Subjective Data: (Information the patient tells you regarding themselves: Biased Information):
Chief Compliant: (In patient’s exact words)
History of Present Illness: (Analysis of current problems in chronologic order using symptom
analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated
symptoms and treatments tried]).
PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major
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medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history,
obstetric and history sexual history).
Significant Family History: (Includes family members and specific inheritable diseases).
Social History: (Includes home living situation, marital history, cultural background, health
habits, lifestyle/recreation, religious practices, educational background, occupational history,
financial security and family history of violence).
Review of Symptoms: (Review each body system – This section you should place POSITIVE for…
information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ;
ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:;
Neurological:; Endocrine:; Hematologic:; Psychologic: .
Objective Data:
Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .
Physical Assessment Findings: (Includes full head to toe review)
HEENT:
Lymph Nodes:
Carotids:
Lungs:
Heart:
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Abdomen:
Genital/Pelvic:
Rectum:
Extremities/Pulses:
Neurologic:
Laboratory and Diagnostic Test Results: (Include result and interpretation.)
Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of
priority.)
Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as
education and counseling provided).
NAME PLAN OF CARE 3
References
—-
NAME OF CARE PLAN 1 is the running head.
Plan of Care Title
Name
Online at South University
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Name of the Professor
NSG 6001 is a non-standard number.
Date
PLAN OF CARE 2 NAME
**To make the document shorter, please remove this statement and anything in italics before submitting it.
of your research paper
Initials of the Patient
Subjective Data (Information about the patient that the patient tells you: Biased Information):
(Patient’s exact words) Chief Compliant
(Analysis of current problems in chronological order using symptom information.)
[onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated factors] analysis
Symptoms and treatments that have been tried]).
PMH/Medical/Surgical History: (Includes medications and why you’re taking them, allergies, and any other significant issues.)
medical issues, immunizations, injuries, hospitalizations, surgeries, and psychiatric history are all things to consider.
sexual history and obstetric history).
Significant Family History: (Includes family members and specific inheritable diseases).
Social History
