This document is a concept map template for a nursing student to document care provided to a patient. It includes sections for patient information, history of present illness, medical/surgical/social history, admission details, lab results, diagnostic tests, cultural considerations, medications, assessment of body systems, nursing diagnoses, plan of care, and evaluations. The extensive template allows the student to comprehensively document all relevant details about a patient's care during their hospital stay or clinical rotation.

1. Concept Map (TEMPLATE)
Student Name:
Instructor:
DATE Care Provided and UNIT:
Patient Information
(1)
Patient Initials:
Age & Gender:
Height/Weight:
Code Status:
Living Will/ DPOA:
History of Present Illness (HPI), Pathophysiology of Admitting
Dx (Cite References) Medical, Surgical, Social History (1).
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT
EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN
THEY GOT TO THE HOSPITAL- UNTIL NOW WHEN YOU
ARE PROVIDING CARE? (USE SEPARATE ATTACHED
WORD DOC WHEN NEEDED)
Medical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED MEDICAL PROBLEMS

2. Surgical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED SURGICAL PROBLEMS
Social History:
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE
/MARIJUANA USEALCOHOL/ ELICIT DRUG USE
Chief Complaint
Admitting Diagnosis & Admission Date
Erickson’s Developmental Stage Related to pt. & Cite
References (1) *List and Discuss specific stage (based on
objective assessment)
Cultural considerations, ethnicity, occupation, religion, family
support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual
Orientation & Psychosocial Considerations/Concerns: include
the following Social Determinants of Health (SDOH)
❋Economic Stability ( MAY DELETE THESE ‘TIPS” TO
USE SPACE)

3. ❋ Education
❋Social and Community Context
❋ Health and Health Care
❋ Neighborhood and Built Environment
Concept Map (TEMPLATE)
Student Name:
Instructor:
DATE Care Provided and UNIT:
Key Diagnostic Tests/ Procedures and Lab Results with Dates
and Normal Ranges (3)
Lab Tests
Normal Ranges
Admission Lab Values
Current Lab Values
Explain Abnormal Labs R/T Your Pt

6. INCLUDE: Appropriate Diagnostic Tests/ Procedures- DATEs
and RESULTS
(Can add See attached Word Doc)
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to
TRANSFER or DISCHARGE
EQUIPMENT ( MAY DELETE THESE ‘TIPS” TO
USE SPACE)

7. MEDS
TREATMENT
REFERRALS NEEDED
Medical Management and Collaborative Plan
(from MD, PT, OT notes….etc.) *Consider past 24 – 48 hours
Patient Education (In Pt.) for Transfer/ Discharge Planning
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
Medications & Allergies (2)
Medication Name
Dose
Route
Freq.
Indications (PRN meds must include MD ordered Indication)
Mechanism of Action
Side Effects/
Adverse Reactions

8. Nursing Considerations
RN Considerations

12. Concept Map (TEMPLATE)
Student Name:
Instructor:
DATE Care Provided and UNIT:
Respiratory (7)

13. Cardiovascular (6)
Vital Signs (4)
Neurological (5)
ASSESSMENT/
REVIEW OF SYTEMS

14. Musculoskeletal
(8)
GI
Hydration/Nutrition (9)
GU (10)
Rest/ Exercise (11)

15. Integumentary (12)
Misc.
Psychosocial (14)
Endocrine (13)
Concept Map (TEMPLATE)
Student Name:
Instructor:
DATE of Care Provided and UNIT:
Priority Nursing Diagnosis #1
Priority Nursing Diagnosis #2

16. PLAN OF CARE
Evaluation #1
Intervention #1
At Risk Dx.-
Outcome/Goal #1
Outcome/Goal #1
At Risk Interventions
At Risk Outcomes/
Goal
Evaluation #2

17. At Risk Evaluation Plan
Interventions # 2
(VM/GP/KL-V5)