Jose Rizal Memorial State University

College of Nursing & Allied Health Sciences

Main Campus, Dapitan City

DAILY PLAN OF ACTIVITIES

Score: _____/20

Name: _______________________________ Date: _____________________

Shift: _______________________________ Assigned Patient: _______________________
Area: _______________________________ Pt’s Diagnosis: _________________________
Instructor: _____________________________ _________________________

I. SETTING OF OBJECTIVES

A. GENERAL OBJECTIVES (GO) – 5 POINTS

B. SPECIFIC OBJECTIVES (SO) – 5 POINTS

II. PLAN OF ACTIVITIES (10 POINTS)

STATUS
SO SPECIFIC ACTIVITY NOT
REMARKS
DONE
DONE

DATE RECEIVED: _______________________

DATE RETURNED: _______________________
CI’S NAME: ____________________________
SN’S SIGNATURE: _______________________
CI’S SIGNATURE: _______________________
 Jose Rizal Memorial State University
College of Nursing & Allied Health Sciences
Main Campus, Dapitan City

ANNOTATED READING
Score: _____/20

Name: _______________________________ Date: ____________________

Area: _______________________________ Instructor: _____________________________
Reference/Source: ___________________________________________________________________
Author/s: ___________________________________________________________________________

Note: The original source must be photocopied and clipped to this page. The journal must be from a
known nursing journal written at least 2013 to present, at least three (3) paragraphs long, and must be
relevant to nursing practice.

DATE RECEIVED: _______________________

DATE RETURNED: _______________________
CI’S NAME: ____________________________
SN’S SIGNATURE: _______________________
CI’S SIGNATURE: _______________________
 Jose Rizal Memorial State University
College of Nursing & Allied Health Sciences
Main Campus, Dapitan City

PATIENT’S PROFILE & HISTORY

Score: _____/30

Name: _______________________________ Date: _____________________

Shift: _______________________________ Instructor: _____________________________
Area: _______________________________

I. PATIENT’S PROFILE (10 POINTS)

Patient’s Name: ________________________ Age: ____ Gender: _______ Civil Status: _______
Address: _____________________________________________________ Ethnicity: _________
Occupation: ___________________________ Attending Physician: ________________________

II. SOURCE OF HISTORY (20 POINTS)

Source’s Name: ________________________ Age: ____ Gender: ________

Relationship to Patient: __________________________ Reliability: (GOOD) (FAIR) (POOR)

III. REASON FOR SEEKING CARE

IV. HISTORY OF PRESENT ILLNESS (HPI)

V. PAST MEDICAL HISTORY

VI. FAMILY HISTORY (GENOGRAM)

DATE RECEIVED: _______________________

DATE RETURNED: _______________________
CI’S NAME: ____________________________
SN’S SIGNATURE: _______________________
CI’S SIGNATURE: _______________________
 Jose Rizal Memorial State University
College of Nursing & Allied Health Sciences
Main Campus, Dapitan City

GORDON’S ASSESSMENT
Score: _____/20

Name: _______________________________ Date: _____________________

Shift: _______________________________ Assigned Patient: _______________________
Area: _______________________________ Pt’s Diagnosis: _________________________
Instructor: _____________________________ _________________________

I. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN

II. NUTRITIONAL/METABOLIC PATTERN

III. ELIMINATION PATTERN

IV. ACTIVITY/EXERCISE PATTERN

V. SLEEP/REST PATTERN

VI. PERSONAL HABITS

VII. COGNITIVE/PERCEPTUAL PATTERN

 Jose Rizal Memorial State University
College of Nursing & Allied Health Sciences
Main Campus, Dapitan City

VIII. SELF-PERCEPTION PATTERN

IX. SEXUALITY/REPRODUCTIVE PATTERN

X. COPING/STRESS MANAGEMENT PATTERN

XI. VALUES/BELIEF PATTERN

DATE RECEIVED: _______________________

DATE RETURNED: _______________________
CI’S NAME: ____________________________
SN’S SIGNATURE: _______________________
CI’S SIGNATURE: _______________________
 Jose Rizal Memorial State University
College of Nursing & Allied Health Sciences
Main Campus, Dapitan City

PHYSICAL ASSESSMENT
Score: _____/20

Name: _______________________________ Date: _____________________

Shift: _______________________________ Assigned Patient: _______________________
Area: _______________________________ Pt’s Diagnosis: _________________________
Instructor: _____________________________ _________________________

SYSTEM SUBJECTIVE DATA OBJECTIVE DATA NURSING DIAGNOSIS

General Health
Survey

Integumentary
System

HEENT (Head &

Face, Eyes, Ears,
Nose, Oral Cavity)

Neck

Respiratory
System

Cardiovascular
System

Breast & Axilla

Gastrointestinal
System &
Abdomen

Genitourinary/
Reproductive
System

Musculoskeletal
System (Upper &
Lower Extremities)

Neurologic System

Lymphatic/
Hematologic
System

DATE RECEIVED: _______________________

DATE RETURNED: _______________________
CI’S NAME: ____________________________
SN’S SIGNATURE: _______________________
CI’S SIGNATURE: _______________________
 Jose Rizal Memorial State University
College of Nursing & Allied Health Sciences
Main Campus, Dapitan City

DRUG STUDY
Score: _____/30

Name: _______________________________ Date: _____________________

Shift: _______________________________ Assigned Patient: _______________________
Area: _______________________________ Pt’s Diagnosis: _________________________
Instructor: _____________________________ _________________________

DRUG DRUG

GENERIC NAME

CLASSIFICATION

INDICATIONS

MECHANISM OF
ACTION

SIDE EFFECTS &

ADVERSE
REACTIONS

DRUG
INTERACTIONS

NURSING
CONSIDERATIONS

PATIENT
TEACHINGS

DATE RECEIVED: _______________________

DATE RETURNED: _______________________
CI’S NAME: ____________________________
SN’S SIGNATURE: _______________________
CI’S SIGNATURE: _______________________
 Jose Rizal Memorial State University
College of Nursing & Allied Health Sciences
Main Campus, Dapitan City

NURSES’ NOTES (FDAR)

Client’s Name: ___________________________ Age: _______ Gender: ________ Ward: __________

DATE
FOCUS DATA – ACTION – RESPONSE
TIME/SHIFT

DATE RECEIVED: _______________________

DATE RETURNED: _______________________
CI’S NAME: ____________________________
SN’S SIGNATURE: _______________________
CI’S SIGNATURE: _______________________
 Jose Rizal Memorial State University
College of Nursing & Allied Health Sciences
Main Campus, Dapitan City

MEDICATION ADMINISTRATION RECORD (MAR)

Client’s Name: ___________________________ Age: _______ Gender: ________ Ward: __________

DATE/ DATE/ DATE/ DATE/

MEDICINES
TIME TIME TIME TIME

DATE RECEIVED: _______________________

DATE RETURNED: _______________________
CI’S NAME: ____________________________
SN’S SIGNATURE: _______________________
CI’S SIGNATURE: _______________________
 Jose Rizal Memorial State University
College of Nursing & Allied Health Sciences
Main Campus, Dapitan City

NURSING CARE PLAN

Name: _______________________________ Date: __________________ Shift: ____________ Area: ________________ Score: ______/30
Assigned Patient: _______________________ Pt’s Diagnosis: ___________________________________________________ Instructor: _____________________________

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE DATA PROBLEM IDENTIFIED SHORT-TERM OBJECTIVES INDEPENDENT SHORT-TERM OBJECTIVES

(WITHIN THE SHIFT)

NURSING DIAGNOSTIC
STATEMENT (2- OR 3-PART)

OBJECTIVE DATA

CAUSE ANALYSIS (WITH

REFERENCE) LONG-TERM OBJECTIVES DEPENDENT/COLLABORATIVE LONG-TERM OBJECTIVES
(UNTIL DISCHARGE)

REFERENCE/S: ___________________________________________________________________________________________ DATE RECEIVED: _______________________

DATE RETURNED: _______________________
CI’S NAME: ____________________________
SN’S SIGNATURE: _______________________
CI’S SIGNATURE: _______________________
 Jose Rizal Memorial State University
College of Nursing & Allied Health Sciences
Main Campus, Dapitan City

LABORATORY/DIAGNOSTIC TEST RESULTS

Score: _____/20

Name: _______________________________ Date: _____________________

Shift: _______________________________ Assigned Patient: _______________________
Area: _______________________________ Pt’s Diagnosis: _________________________
Instructor: _____________________________ _________________________

LAB/DX TEST LAB/DX TEST

DATE

NORMAL/
REFERENCE
VALUES

RESULT

INTERPRETATION
(RELATE WITH
DIAGNOSIS)

NURSING
RESPONSIBILITIES
(PRE- & POST-TEST)

REFERENCE/S: ______________________________________________________________________________

DATE RECEIVED: _______________________

DATE RETURNED: _______________________
CI’S NAME: ____________________________
SN’S SIGNATURE: _______________________
CI’S SIGNATURE: _______________________
 Jose Rizal Memorial State University
College of Nursing & Allied Health Sciences
Main Campus, Dapitan City