PT age, dx, gender,
surgery & post op day,
living situation including stairs and care persons, level of independence
References (APA format)
(article summary on separate document)
Assessment
Data
Labs/diagnostic tests
Objective
Subjective
Mobility
Chart
Cultural considerations
Nursing Process
Goal or Outcome
3 Nursing Interventions
Evaluation on your shift
(goal met partially or completely)
NSG diagnosis r/t (condition) aed (data)
Goal or Outcome
3 Nursing Interventions
Evaluation on your shift
(goal met partially or completely)
NSG diagnosis r/t (condition) aed (data)
Goal or Outcome
3 Nursing Interventions
Evaluation on your shift
(goal met partially or completely)
NSG diagnosis r/t (condition) aed (data)
Medications
Routine
Prn's