PATIENT PROFILE DATA FORM

Student Name: Patient Identifier: Gender: Male Female Advance Directives Living Will: yes no Date of Care: Age: Admission Date: Do Not Resuscitate Order (DNR) yes no

Medical Durable Power of Attorney: yes no (If yes, relationship?) Reason for Hospitalization: Significant Medical Diagnoses: Relevant Surgical Procedure(s) and Date(s): Pathophysiology/Description of present illness/medical diagnoses or surgical procedures (Continue on back of this page, no less than 3-5 sentences per diagnosis/procedure, include how the present illness/condition relates to or is impacted by co-morbidities or previous illness, symptoms to watch for and any current treatments pertinent to the patient)

Laboratory Data Students MAY NOT use the term WNL or chart by exception on this form. Write normal value range, exact value for patient, and indicate if this is normal, high, or low. Sodium Positive Cultures Potassium Chloride Serum CO2 Glucose Insulin Therapy? Blood Urea Nitrogen Creatinine Calcium Magnesium Phosphorous Total Protein Albumin Pre-Albumin White Blood Cells Red Blood Cells Hemoglobin Hematocrit Platelets INR Coumadin Therapy? PTT Heparin Drip? Total Bilirubin AST ALT Alkaline Phosphatase

OTHER: (HGB A1c, amylase, lipase, ammonia, CPK, troponin, BNP, lactate, ABG pH, pO2, pCO2, HCO3)

What information can you obtain from these lab values? Why is this information important for this specific patient?

Diagnostic Tests Date completed and findings Chest X-Ray: EKG/Telemetry: Other:

CT/MRI:

**Write exactly what you see/hear/etc. and indicate if this is normal, abnormal, hyper, or hypo; if abnormal then state pathophysiology resulting in abnormal assessments students MAY NOT use the term WNL or chart by exception on this form. Physical Assessment Data T-P-R: Height: Pain rating on 0-10 scale: BP: Weight: Pain Assessment Details (OLD CART):

Last pain medication given (What was given and when):

Treatments (Eg: PT, OT, RT, etc) Treatment: Support Services: Other:

Treatment: Consultations:

Diet/fluids Type of diet: Fluid intake: Needs assistance with feeding Other:

Restrictions: Tube feedings (type and rate): Nausea or vomiting:

Appetite: Problems swallowing, chewing, dentures: Over-hydrated or dehydrated (how assessed):

Intravenous Fluids Type and rate: Condition of site and dressing:

Site(s) Other:

Elimination Last bowel movement (LBM): Circle problems that apply:

24 hour urine output: Bowel Constipation Diarrhea Flatus Hesitancy Incontinence

Catheter yes no Type: Urinary Pain/Burning Frequency Odor

Neurological/Mental Status LOC & Orientation: Speech: Memory (recent, remote):

Motor (ROM, gait, balance): Pupils (PERRLA): Sleep habits (meds, etc.)

Sensory Deficits (hearing, vision, taste, smell, sensation):

Musculoskeletal System Ability to walk/Gait: Transfers: ROM/Muscle Strength (weakness, paralysis): Bones, Joints, Muscles (fractures, contractures, arthritis, spinal curvatures, etc.) : Fall risk assessment (score and classification of risk):

Type of activity orders: Mobility aides: Restraints yes no Cast/Splint/Collar/Brace:

Side rails (number):

Cardiovascular system Extremity Circulation Checks (pulses, temperature, sensation, color): Neck Vein Distention: Sounds(S1, S2, regular/irregular): Respiratory System Airway (type, size): Cyanosis yes no Location: Breath Sounds (clear, crackles, wheezes, rhonchi, location): O2 humidification: Yes No Chest tube or other: Chest Pain:

Capillary Refill: Edema (degree, pitting, location): TED Hose, Compression Devices: Yes No Type: Use of accessory muscles: Cough (productive, nonproductive): Flow rate of O2: Smoking History Yes No

Depth, rate, rhythm: Sputum (color, amount): Use of O2 (nasal cannula, mask, trach collar): Pulse Oximetry: ____ % oxygen saturation

Gastrointestinal System Abdomen (pain, tenderness, guarding, distention, soft, firm): NG tube (describe drainage): Other: Skin and Wounds Color & Condition: (intact, rash, bruising, turgor) Edges approximated? Yes No Dressings (clean, dry, intact):

Bowel sounds:

Ostomy (describe stoma site & drainage):

Describe wound(s) location, size: Characteristics of drainage: Braden Risk Assessment (score and classification of risk):

Drains (type & location): Wound Closures (sutures, staples, steri-strips, other):

Other:

Head, Eyes, Ears, Nose, Throat (HEENT) Oral Mucous Membranes/Tongue (color, moisture, lesions): Eyes (redness, drainage, edema, ptosis): Nose (redness, drainage, edema): Reproductive System Female: LMP: # Pregnancies/# Live births: Vaginal discharge/bleeding: History of STIs: Last Mammogram: Last Pap Smear: Psychosocial and Cultural Assessment Religious preference: Primary Language: Emotional state:

Teeth (dentures, dental caries, edentulous): Ears (drainage, tinnitus): Throat (pain, redness, gag reflex):

Male: Any prostate problems: ED problems: Penile discharge/bleeding: Last Prostate Exam: History of STIs: Other:

Marital status: Occupation: Family interaction:

Patient/Family Education Education Materials Provided (Any available/utilized that apply to diagnosis):