1 pts
2 pts
3 pts
4 pts
Summarize events leading up to admission, why brought to this facility. Need subjective data "according to patient", objective data, "according to chart, family, etc. Documentation is clear and well organized
Social, cultural, spiritual, developmental, support system, environmental facotrs.
Include times, frequency and important supportive data.
Pertinent lab/ x-ray, diagnostic procedure results within the last 30 days. Must include CBC, metabolic profile and medication specific tests even if past 30 days, use latest. List normal ranges and highlight abnormals with the reason you suspect they are abnormal r/t pt. DX.
Relate to head to toe assessment, diagnosis and treatments
Follows Medication card format and includes all required data such as classification, brand/generic name, actions, side effects, nursing considerations, etc.