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4 pts
List Chief complaint or admitting medical diagnosis. Complete a paragraph or two about the underlying illness, including the pathophysiology.
Data gathered using subjective and objective; utilize patient and family, physical assessment and data available in EMR and paper chart.
Abnormal lab data reported with explanations related to patient illness.
Include a list of patient medications with explanation of why each medication was prescribed. Also include your worksheet for medications.
Need to list at least 3 nursing problems/diagnoses, show priorization of care based on patient's needs.
Need to have 2 short term and 1 long term goal for each nursing diagnosis.
Need to have minimum of 3 interventions per goal. Rationale for each intervention need to show the justification for using this particular intervention for the desired outcome.
Attention should be paid to making your concept map easy to read, logical, & neat.