Care plan
Ivy Tech Community College of Indiana
Nursing Program – Region 6
Nursing Care Plan and Evaluation
Student: __ Instructor: _Date: _1-28-2010_____ Instructions:
1. The nursing care plan evaluation is based upon the application of criteria appropriate for the student’s skill set.
2. All nursing care plans must be typed (Times New Roman, 12 point font). The nursing care plan form is available on Blackboard™ in each clinical course.
3. The grading rubric must be attached – last page of nursing care plan.
4. All relevant assessment tools used (physical, psychological, or psychiatric i.e. Braden Skin Assessment, Fall Risk) must be attached.
HIPAA (Health Information Privacy and Protection Act) mandates all health care providers protect patient privacy. Only information that the patient specifically releases may be shared with others. Only professional persons (students and instructors) involved in care are allowed access to the health care information. The student should be cautious about what information is shared verbally and with whom. If the student is approached for patient information by someone who purports to have authority, the best course of action is to refer that individual to the appropriate administrative personnel.
IVY TECH COMMUNITY COLLEGE OF INDIANA – REGION 6
NURSING PROGRAM
NURSING HISTORY & PHYSICAL ASSESSMENT FORM
Student _________________________ Date of Care __1-26-2010 to 1-27______
Facility/Unit _Oncology_BMH___ Instructor
Health History
Biographical Data:
Patient's Initials _DH___ Age __79__ Gender__F__ Martial status: Widow__ DOB: _7/29/1930__________
Birthplace: Randolph County__ Ethnic origin/Race: _Caucasian_ Occupation: previous factory worker_
Work status : retired_________ Educational background __High school______________
History source initials ___Pt__ Relationship to client __self__________________
Nursing Program – Region 6
Nursing Care Plan and Evaluation
Student: __ Instructor: _Date: _1-28-2010_____ Instructions:
1. The nursing care plan evaluation is based upon the application of criteria appropriate for the student’s skill set.
2. All nursing care plans must be typed (Times New Roman, 12 point font). The nursing care plan form is available on Blackboard™ in each clinical course.
3. The grading rubric must be attached – last page of nursing care plan.
4. All relevant assessment tools used (physical, psychological, or psychiatric i.e. Braden Skin Assessment, Fall Risk) must be attached.
HIPAA (Health Information Privacy and Protection Act) mandates all health care providers protect patient privacy. Only information that the patient specifically releases may be shared with others. Only professional persons (students and instructors) involved in care are allowed access to the health care information. The student should be cautious about what information is shared verbally and with whom. If the student is approached for patient information by someone who purports to have authority, the best course of action is to refer that individual to the appropriate administrative personnel.
IVY TECH COMMUNITY COLLEGE OF INDIANA – REGION 6
NURSING PROGRAM
NURSING HISTORY & PHYSICAL ASSESSMENT FORM
Student _________________________ Date of Care __1-26-2010 to 1-27______
Facility/Unit _Oncology_BMH___ Instructor
Health History
Biographical Data:
Patient's Initials _DH___ Age __79__ Gender__F__ Martial status: Widow__ DOB: _7/29/1930__________
Birthplace: Randolph County__ Ethnic origin/Race: _Caucasian_ Occupation: previous factory worker_
Work status : retired_________ Educational background __High school______________
History source initials ___Pt__ Relationship to client __self__________________