mini care

School of Health Professions, Science and Wellness

Department of Nursing

Clinical log (Mini Care Plan)

Client Code Name: _____________________________

Client’s Age: _________ Gender: ________________

Present Medical Diagnoses: ____________________________________________________________________________

Present Surgery (if applicable): _____________________

Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):

____________________________________________________________________________________________________

Spiritual Well-Being: __________________________________________________________________________________

Allergies: __________________________ Code Status: _________________________

Vital Signs: T_____________ P_____________ R____________ BP______________ SPO2__________

General Appearance:

Psychiatric:

HEENT:

Neck and Lymph Nodes:

Pulmonary:

Cardiovascular:

Skin and Nails:

Abdomen:

Genitourinary:

Pelvic and Rectal:

Extremities:

Musculoskeletal:

Neurological (DTR’s, reflex grading, cranial nerve evaluation):

Incisions:

Drains:

Diet/Nutrition:

IVs: Intake and Output:

Fall Risk Assessment (include score): Pressure Ulcer Risk Assessment (include score):

Pain assessment (include reassessment):

Time	Score	Intervention	Reassessment Time	Score

Diagnostic Assessments – Important EKGs, X-Rays, and Labs

Lab/Other Test	Patient values	Inference

Medications Ordered for Client:

Medication and Dose with Brand name	Generic Name of Drug	Times of Administration	Indications of Drug	Adverse Effects	Nursing Implications

Treatments and Procedures	Day & Times	Rationale

Nursing Interventions:

Assessment Findings	Nursing Diagnoses	Expected Outcomes	Nursing Interventions	Evaluation

Reflections of the day: