NR 341 Patient Centered Clinical Care Packet

Plan 1

 This assignment is to be completed at the discretion of the clinical instructor

 The student will not physically remove any information from the patient’s chart / clinical agency for any reason. Removing

is defined as leaving the chart, leaving the unit, floor and or clinical agency regardless of concealing identifying information.

This would be a HIPAA violation

 This cover sheet is to remain on all clinical preparation tools at all times.

DATA COLLECTION SHEET

Patient Initials: L.F. Room # 203 DOB: 1/12/1963 Age: 52 Gender: Female Date admitted 1/25/2017

Admitted to facility Date: 1/25/2017 Resuscitation Status: Full Code

Allergies: No Known Allergies Reaction: N/A

Reason for Admission: Pt. was found down in a park with a large Right forehead laceration and no witnesses as to

what happened to her, or why she may have originally passed out. Patient was unresponsive, combative and in an

altered state of consciousness.

Medical diagnoses r/t this admission: Right forehead laceration, unprotected airway due to current state of

consciousness, her GCS was a 9 on admit.

Is patient aware of all dx? During ventilation vacation, patient became aware of her diagnosis. She is aware of her

own drug and alcohol abuse history.

Other medical, psychological, psychiatric diagnoses: ETOH Abuse, Narcotic abuse

Health condition prior to this admission: Fair to poor, due to substance abuse, but no other diagnosis have been

made.

Past and current surgeries/procedures and dates: Unknown due to ventilated status.

Medications presently taken at home and why? Unknown.

Use of prescribed/complementary medications: N/A

Environmental/ambulation aids used (glasses, hearing aid, cane, brace, w/c, ramps): N/A

Social: Single Significant other, Next of Kin or POA for Health Care: Sister is next of Kin but has no power of attorney.

Occupation or former occupation: Unemployed, lives in a half way house.

Financial challenges: Uninsured

Housing: Lives in a halfway house, try to become sober.

Religion/considerations? None

Culture/considerations? None

Presence of family, supportive individuals/relationships: Sister was contacted and is now at bedside. 

NR341 Clinical Documents Revised May 2016 Chamberlain College of Nursing—Phoenix campus

Plan for care after discharge (home, transitional care, SNF, home care) The patient will likely be discharged and enter

into a rehab facility with the help of her sister so that she is able to be successful with her sober living. At this point

however, she needs to prove that she will be able to breathe off the machine and that she has the appropriate level

of cognitive mental function after her injury