วิทยาลัยพยาบาลบรมราชชนนี กรุงเทพ

วิชาปฏิบัติการรักษาพยาบาลขั้นต้น
แบบบันทึกรายงานปฏิบัติการรักษาพยาบาลขั้นต้น (Long Case)
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1.Student Data : Name ….……………………………………………....…………………........No…………….............
2.Hospital……………………………………………………..Date………………………………………………………………......
3.Patient Data : Name …………….……………………………H.N………………………………..age……………..…....
Sex………………….Marriage status………….Occupation………………..…………..…………….
Home town……………………………..Address…………………………………………………………….
Information Source: Obtained from …………………………Reliable……………%
4.Chief complaint
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5.Present illness
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6.Past history :
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7.Personal history :
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8.Menstrual History / Birth Control

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9.Family history :
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10. Family genogram

11.Addition to Pediatric History ( Pediatric case only )

Mother health in pregnancy and labor………………….……………………………………..……………...
Complication …………………………………………………………………………………………………..………..…......
Birth place………………………………………..…………………………………………..…………………………….........
Birth weight and height ……………………………………………………………………………………….............
Feeding and development ………………………………………………………………………………..….…….....
Immunization history
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12.Review of Systems (interview):

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13. Physical examination
Vital signs: T…………………… P…………………… R………………………. BP……………….………
Weight………………………….kgs. Height………………………..…cms , BMI…………….…………….
General…………………………………………………………………………………..…………………………………………..……….
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Skin……………………………………………………………………………………..………………………………………………………
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Head…………………………………..…………………………………………………………………………………………………………
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Eyes………………………………..…………………………………………………………………………………………………..………
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Ears……………………..…………………………………………………………………………………………….…………………………
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Nose……………………..…………………………………………………………………………………………….………………………
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Mouth and throat……………..……………………………………………………..……………………………………………..
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Neck & Lymph nodes
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Breast…………………………………………………………………………..…………..…………………………………………………
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Respiratory System………………..…………………………………………..………………………………………………..….
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Cardiovascular System……………………………………..…………………..…………………………………………..………
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Gastrointestinal System………………..………………………………………………………………………..……..............
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Urinary System………………………………..……………………………………………………..…………………….…………….
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Reproductive System……………………..………………………………………………………………….…………………...
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Hematological System……………..…………………………………………………………………………………………….……
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Endocrine System……………………………………………………..……………………………………………….……………..
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Neurological System………………………………………………..………………………………………………………………..
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Others……………………………………………………………………………..…………………………………………..………………
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14.Laboratory Findings (ถ้ามี)
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15.Problem lists
15.1 from illness
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15.2 from disease

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16. Differential diagnosis:
1............………………………………………………………………………………………………………………………………………..
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17.Final Diagnosis and Supportive Data:
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18.Treatments :
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19.Health Education and Health Counseling

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20. Planning for Home visiting and Activities
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21.Instructor ,s Comments :
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Instructor Signature ………………………….……………………..

Trainee, s Signature………………………………..…………….
Date……………………….……..………………….

BCN, Bangkok Nu 021417-FM-01 issue 1. rev. 1 09/09/65