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History Collection
Bi graphic Data »
Patient's name
―
Age/sex ―
Address ―
Addmission Date ―
Language ―
Ward No. ―
Bed No. ―
Religion ―
Patient's occupation ―
Diagnosis ―
chief complain
―
―
―
―
Socioeconomic status »
past medical history »
past surgical history »
History of present illness »
:: Family History »
:: Family tree »
:: Family key »
:: Personal History »
Diet pattern -
Appetite -
:: Bladder Pattern»
In Day -
In Night ―
HEAD TO FOOT
EXAMINATION
General apprence ―
Body Build ―
Health ―
Activity ―
Mental status ―
consciousness ―
Look ―
Posture ―
Body curves ―
Moment ―
Height & Weight ―
Skin condition ―
Colour ―
Temperature ―
Lesions ―
Texture ―
Head & Face ―
Scalp ―
Skull ―
Face ―
Eye Brows ―
Eye Balls ―
Conjunctiva ―
Pupils ―
Lens ―
Vision ―
Hearing ―
Nos trils ―
Mouth & Pharynx ―
Lips ―
Odour of mouth ―
Teeth ―
Tongue ―
Throat & Pharynx ―
Neck ―
Range of motion ―
Chest ―
Breath sound ―
Heart sound ―
Abdomen ―
Observation ―
Auscultion ―
Palpation ―
Percussion ―
Extremities ―
Uper extremities ―
Lower extremities ―
Genitals & Rectum ―
Vital sign
I v s ga n
Medica ns
Nursing Diagn sis

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Nursing care Plan Format by Maheshwari

  • 1. History Collection Bi graphic Data » Patient's name ― Age/sex ― Address ― Addmission Date ― Language ― Ward No. ― Bed No. ― Religion ― Patient's occupation ― Diagnosis ― chief complain ― ― ― ―
  • 2. Socioeconomic status » past medical history » past surgical history » History of present illness » :: Family History »
  • 3. :: Family tree » :: Family key » :: Personal History » Diet pattern - Appetite - :: Bladder Pattern» In Day - In Night ―
  • 4. HEAD TO FOOT EXAMINATION General apprence ― Body Build ― Health ― Activity ― Mental status ― consciousness ― Look ― Posture ― Body curves ― Moment ― Height & Weight ― Skin condition ― Colour ― Temperature ― Lesions ― Texture ―
  • 5. Head & Face ― Scalp ― Skull ― Face ― Eye Brows ― Eye Balls ― Conjunctiva ― Pupils ― Lens ― Vision ― Hearing ― Nos trils ― Mouth & Pharynx ― Lips ― Odour of mouth ― Teeth ― Tongue ― Throat & Pharynx ―
  • 6. Neck ― Range of motion ― Chest ― Breath sound ― Heart sound ― Abdomen ― Observation ― Auscultion ― Palpation ― Percussion ― Extremities ― Uper extremities ― Lower extremities ― Genitals & Rectum ―
  • 7. Vital sign I v s ga n Medica ns