Clinical Documentation Template

For NURS 6755, 6756, 6757, 6758

Student_______________________________Site________________________________
Client’s Initials______________Age_______Gender____________Date___________

Subjective

Chief Complaint:

HPI:
Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Pertinent Positives, Pertinent Negatives, etc. for each complaint

ROS (write out by system):

Past Medical History:

Surgeries:

Hospitalizations:

Allergies:
Food, drug, environmental

Medications:

Family History:

Social History:

Nursing Data Base:

Objective
Vital Signs: HR BP Pulse RR Pain LMP Height Weight BMI SpO2

Labs:

General Survey:

Exam (write out by system):

Assessment

Statement:

Problem List (diagnosis):

Differentials (with rationale for each):

Plan (3 pronged-plan for each problem on the problem list)

Diagnostics:

Treatment:

Education: