Title
Student Name
School of Nursing, Liberty University
Course #: Course Name
Instructor Name
Date
1
PATIENT PROFILE WORKSHEET
Clinical Date: __ / __ / __
A. Personal Information
Room # __ Gender __ Ethnicity __ Age if <90 __
Place of Residence: __ MD __
Emergency Contact: __ Marital Status __
Admitting Diagnosis: __
Co-Morbidities: __
Date of Admission: __ Date of Surgery: __ Allergies: __
Code Status: __ Mental Status: __
B. Activity and Nutrition
Diet order: __ Route/Rate: __ Last Wt: __
Level of Activity (bedrest, up ad lib, BRP, turning): __
Level of self-care: __
C. Nursing Care
Drainage devices (foley, NGT, JPs, T-tube, etc.): __ NGT Flushes: __
Wound care/Dressing (be specific): __
IV access (peripheral, central, location, care): __
IVF: __ @ __ mL/hr Saline Lock? __ TPN? __
Frequency of vital signs (including pulse oximetry): __
Frequency of Glucometer: __ Supplemental oxygen: __ OSA __
Falls Risk __
Precautions: __
2
Most Recent Labs
Lab Normal range Patient value Date/time Out of range?
CBC
WBC
RBC
Hb
Hct
MCV
MCH
MCHC
RDW
Plts
CHEM 12
Na+
K+
Cl-
TCO2
Anion Gap
Glucose
BUN
Cr
Calcium
Total protein
Albumin
AST
ALK
Total bilirubin
ALT
GFR
Osmolality
OTHER LABS
(Reference, year)
Other Diagnostic Tests
Diagnostic Study Date & Time Results
EKG
3
RADIOLOGY EXAMS
Vital Signs
Date/Tim
e
Temp HR RR BP SpO2
PATIENT HISTORY WORKSHEET
Chief complaint:
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History of Present Illness:
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Past Medical History:
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Past Surgical History:
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Family History:
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Tobacco __ Alcohol __ Illegal Drugs __
Occupational Status __
Religious Preference __
Cultural Support Needs __
PHYSICAL ASSESSMENT
GENERAL: (overall assessment)
4
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HEENT: (ED only)
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CARDIAC: (heart sounds, rate, rhythm, pulses, circulation, etc)
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RESPIRATORY: (lung sounds, work of breathing, O2 sat)
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ABDOMEN/GI: (bowel sounds, overall assessment)
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GU: (urinary output, catheters, etc.)
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MUSCULOSKELETAL: (strength, gait, mobility status)
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INTEGUMENT: (list any wounds, dressings, other issues)
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NEURO: (A&O x 4, pupils, etc.)
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5
PATHOPHYSIOLOGY
6
CARE PLAN
Top Three Prioritized Medical and Nursing Diagnosis
1.
2.
3.
Medical & Nursing Dx Nursing Outcomes (NOC) Nursing Interventions (NIC) Evaluation
1. 1.
2.
3.
1a.
1b.
1c.
2a.
2b.
2c.
3a.
3b.
3c.
1.
2.
3.
(Reference, year)
8
https://www.coursehero.com/file/126989721/031-Patient-Profile-Form-2020-New-Formatdocx/
