AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM

NURSING HISTORY

FIRST

Patient Initials: _______ Room No: ______Sex_______ Age________Weight: ______

DAY
Date__________Allergies_____________________________________
Working Medical Diagnosis/ Chief of Complaint________________________ Diet Ordered: _________________Restrictions:
___________________________
Type of Isolation:________________________________DNR Status or Advance
Directives________________________________________________________
Scheduled Procedures or Test: ________________________________Reason for Procedure or Test:
________________________________________________
1. Source of Information: Primary or Secondary
(Specify)_______________
2. Chief Concern (Reason for Admission):
___________________________
3. History of Present Illness (a chronological description of
why the client seeks care; include the onset and severity
of signs and symptoms, treatments used and
corresponding effectiveness, and clients understanding
of the illness):
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
_______________________
4. Past Health History and Current Health Status
a. Childhood Illnesses (a list of previous chronic and
communicable diseases experienced as a child):
_______________________________________________________
_______________________________________________________
_______________________________________________________
______________________________________________________
b. Past Medical Illnesses (a list of the clients past
diseases include the year it was diagnosed):
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
c. Surgical History (a list of the clients previous
operations and the year the surgery was done):
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM
5. Family History (a list of the diseases and or cause of
death among the clients immediate family)
a. Mother
:________________________________________________
b. Father:
_________________________________________________
c. Siblings:
________________________________________________
d. Grandparents:
___________________________________________
e. Partner:
________________________________________________
f. Children:
_______________________________________________
6. Social History:
a. Educational Status (Highest educational level
obtained):
_______________________________________________________
b. Support System (Presence and type) :
_______________________________________________________
c. Concerns about Living Conditions (fire hazards, safety
hazards, fall hazard etc):
_______________________________________________________
_______________________________________________________
_______________________________________________________
d. Ability to perform activities of daily living (identify if
the client is independent, partially dependent for
assistance, or totally dependent for assistance)
- Bathing:
____________________________________________
- Grooming :
__________________________________________
- Walking:
____________________________________________
- Climbing up and down the stairs:
_________________________

Cooking:
_____________________________________________
- Buying medications:
___________________________________
- Taking medications:
___________________________________
- Buying groceries:
______________________________________
- Cleaning:
____________________________________________
- Special medical treatments and treatments at
home:______________________________________________
_
e. Assistive devices (type and reason for use)
_______________________________________________________
_______________________________________________________
Spiritual health (spiritual concerns or requests):
_______________________________________________________
_______________________________________________________
7. Health Promotion Behaviors
a. Recreational Drug use (presence, type, duration):
__________________________________________________________
__________________________________________________________
b. Smoking (how many sticks/ packs per day; how many
total years as a smoker:)
_________________________________________________________
_
c. Alcohol (type, ounces per day or week:)
_________________________________________________________
_
d. Exercise or activity (type, frequency and duration:)
_________________________________________________________
_
e. Diet (clients typical die description:)
__________________________________________________________
__________________________________________________________
f. Sun Exposure (presence, duration)

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM
_________________________________________________________

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
________

_
g. Sexual Practice and Contraceptive Use
______________________________________________________
h. Stress and Coping Mechanisms (sources of stress, the
clients way of coping and the effectiveness of these
coping mechanisms )
_________________________________________________________
_________________________________________________________

ACTIVE MEDICAL DIAGNOSES, CURRENT MEDICATIONS AND DIAGNOSTIC TESTS

Other Active
Medical or
Surgical
Diagnoses

Patients
Medications

(Name, Dose,
Frequency Route);
Please place
medication with the
corresponding
medical diagnoses
(This section does not need to
correspond per row with the diagnostic
section)

Diagnostic Tests

FIRST
DAY

(Only use values that are abnormal)

Name of
Test

Reason for
Test

Normal
Range

Patients Values

Significance

(indicate patients
actual values and if
high or low)

(explain possible
reasons for the
obtained values)

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM

1st DAY

DOCTORS ORDERS
Date
Ordered

Orders

Rationale

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM

ASSIGNED CASE
Chief Complaint or Priority Medical Diagnosis: ______________________________________________
Definition
Pathophysiology

Signs, Symptoms and Abnormal Diagnostic Findings Present in Your Patient

Chief Complaint or Priority Medical Diagnosis: ______________________________________________

Definition
Pathophysiology

2nd DAY

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM
Signs, Symptoms and Abnormal Diagnostic Findings Present in Your Patient

Chief Complaint or Priority Medical Diagnosis: ______________________________________________

Definition
Pathophysiology

Signs, Symptoms and Abnormal Diagnostic Findings Present in Your Patient

Daily Plan of Care

Per Day with Progress Notes

& PE

Identified Nursing Diagnosis (3 part nursing diagnosis

statement):____________________________________________________________________________
Long Term Goals: Weeks to Months
Evaluation
(Please ensure that it is a patient centered goal that is specific,
measurable, attainable, realistic and time bound. Please ensure that
this goal addresses the main problem)

(Please check of the appropriate

status of your client)

( ) Goal Met
Goal Unmet

As Evidenced by
(Please put supporting signs
and symptoms to justify the
identified status of your
patient)

( ) Goal Partially ( )

Short Term Goal: Hours to days

Evaluation

(Please ensure that it is a patient centered goal that is specific,

measurable, attainable, realistic and time bound)

(Please check of the appropriate

status of your client)

As Evidenced by
(Please put supporting signs
and symptoms to justify the
identified status of your
patient)

( ) Goal Met ( ) Goal Partially ( )

Goal Unmet
( ) Goal Met ( ) Goal Partially ( )
Goal Unmet

Planned Interventions
Classification
Interventions (Please put enough interventions to solve or reverse the problem)
Assessment

Implement
ation
Status
( )

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM
(Indicate what you will
be monitoring)

Implementation
(Indicate what you
will be DOING for
the patient)

Completed
( ) Ongoing
( ) Not Done

Rationale
1.

( )
Completed
( ) Ongoing
( ) Not Done

Rationale
2.

( )
Completed
( ) Ongoing
( ) Not Done

Rationale
3

( )
Completed
( ) Ongoing
( ) Not Done

Rationale
( )
Completed
( ) Ongoing
( ) Not Done

Health Teaching
(indicate the topic
you which to teach
your client )

Rationale
Evaluation

( )
Completed
( ) Ongoing
( ) Not Done

(Indicate what will be

monitored after the
interventions has been
done)

DRUG STUDY

Before Medication
Administration
(Include all prescribed medications, over the counter medications and supplemental/ nutritional
or alternative
medications the patient is taking)
Medicatio
ns Name
(Brand and
Generic
Name,
Classificatio

Frequenc
y, Route,
Dose

Safe
Dose
Range

Withi
n
Rang
e?

Indicati
on

Mechanism of
Action

Side
Effects

Contraindica
tions

Top 3 Nursing
Interventions
(Include assessment,
monitoring, special
diets, restrictions and
hold orders)

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM
n)

Yes/N
o

Yes/N
o

Yes/N
o

Yes/N
o

Medicatio
ns Name
(Brand and
Generic
Name,

Frequenc
y, Route,
Dose

Safe
Dose
Range

Withi
n
Rang
e?

Indicati
on

Mechanism of
Action

Side
Effects

Contraindica
tions

Top 3 Nursing
Interventions
(Include assessment,
monitoring, special
diets, restrictions and

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM
Classificatio
n)

hold orders)

Yes/N
o

Yes/N
o

Yes/N
o

Yes/N
o

Yes/N
o

Yes/N
o

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM
AT THE END OF THE ROTATION
Nursing Diagnoses:
3 Priority Actual Nursing Diagnosis
1 Risk Nursing Diagnosis
1 Concept Map to Summarize all Plan of Care Done for the patient
Prioritiza
tion

Justificatio
n of
Prioritizatio
n

Type of
Diagnosis

Actual
Actual
Actual
Risk
Health
Teaching
Concept Map

Last
Day

3 Part Nursing Diagnosis (Diagnostic Label, Etiology and Supporting Cues)

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM

Per Day

Sources:
Tile of the Book/
Website

Author

Year of Publication

Page

Edition

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM

CLINICAL INSTRUCTOR INSTRUCTIONS

How to use these forms:
These packet contains the following documents:

Assessment Documents:
o Physical Assessment
o Nursing History
o Active Medical Diagnoses, Current Medications and
Diagnostic Tests and Laboratories
o Doctors Orders
Assigned Case or Chief Complaint
Daily Plan of Care
Progress Notes
Drug Studies
Synthesis (Concept Map)
Citation of Sources

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM
DESCRIPTION AND INSTRUCTIONS

Assessment Documents:
o Physical Assessment: Our current assessment
is based on Orem s Self-Care Deficit. The forms
are progressively reduced in content from Term 1
to Term 4 to assist the student in learning how to
document the normal and abnormal findings.
Student must perform a physical assessment for
their assigned patient on the first hour per day.
Daily physical assessments must be submitted at
the end of the shift to the instructor. It is
recommended that initial assessments be done
with the instructor for the clients safety.

o Nursing History: This is a short version of the

nursing history. It includes the chief complaint,
history of present illness, past medical illness,
social history, environmental history, family
history and spiritual history. Student must obtain
at least one complete history for the assigned
patient. The client is only interviewed upon being
assigned to the student.

o Active
Medical
Diagnoses,
Current
Medications and Diagnostic Tests and
Laboratories: This is equivalent to the clients
review of records. This is to be completed on the
first day also. Please countersign the page and
validate that the data represents the actual

clients information. Please do not discard the

original records for comparison purposes. The
rationale and relevance of diagnostic tests and
laboratories may be assigned to the student as
homework in preparation for the next clinical day.
o Doctors Orders: This is to be obtained on the
first day also. The rationale for the doctors
orders are to be researched by the student as
homework.

Assigned Case or Chief Complaint: This section

refers to the medical condition or diagnoses that you
assigned to the student. This can be the basis of
their plan of care. Please ensure that assigned cases
are relevant to Term Objectives. For example Term 2
students may be given clients who have
cardiovascular illnesses while Term 3 students can be
given Diabetic clients after they have discussed
Diabetis Mellitus in lecture). Please coordinate with
the theory instructor as to what system they have
completed. The pathophysiology and definition are to
be researched by the students as homework.

Daily Plan of Care: This is to be completed ideally

before any day of implementation. When approving
nursing diagnoses, please prioritize actual nursing
diagnoses over risk nursing diagnoses. Please
correlate the nursing diagnoses with the chief

AMERICAN CAREER COLLEGE,

VOCATIONAL NURSING PROGRAM

complaint or assigned case. The Plan of Care was

formulated to reflect the Nursing Process.

Progress Notes: Please document the interventions

provided to the client on that day. We are
discouraging duplicating the physical assessment
findings on the progress note. The progress note
should reflect routine interventions done for the
patient (range of motion, assisting with feeding etc),
abnormal responses, the interventions that were
implemented and the clients response to these
interventions.
Drug Studies: Please do not allow students to pass
medications unless an 80% or higher score has been
obtained in the drug calculation test. Please validate
the students understanding of the medications and
its relationship to the clients history, medical
diagnoses and diagnostic tests. A student who is
unable to discuss the medications of her client
should not be allowed to pass medications. The
recommendation is for the drug study to be

completed for ALL the assigned patients medications

(not just the ones that the students are currently
administering).

Synthesis (Concept Map): On their last day, the

students are to summarize their client experience. A
concept map is required to show prioritization among
medical diagnoses, nursing diagnoses, interventions
and diagnostic tests. The purpose of the concept
map is to show the relationship of all of the clients
risk factors, medical illness, nursing diagnoses,
diagnostic tests and nursing interventions.
Citation of Sources: These papers are considered
scientific papers. Any information obtained from
literature, websites, reference materials etc must be
properly documented. Please reinforce that we do
not allow plagiarism.