|
A Patient Identification
|
|
Name
|
240 (100%)
|
|
Medical record number
|
240 (100%)
|
|
Age
|
240 (100%)
|
|
Weight
|
232 (96.7%)
|
|
Height
|
232 (96.7%)
|
|
B Initial Assessment
|
|
General appearance
|
240 (100%)
|
|
Consciousness level
|
239 (99.6%)
|
|
Vital signs
|
238 (99.2%)
|
|
History of allergy
|
240 (100%)
|
|
Nutritional screening
|
240 (100%)
|
|
Pain
|
238 (99.2%)
|
|
C Functional Status
|
|
Barthel index
|
238 (99.2%)
|
|
Risk of fall
|
239 (99.6%)
|
|
Risk of pressure ulcer
|
50 (20.8%)
|
|
Educational need
|
231 (96.3%)
|
|
Cultural need
|
211 (87.9%)
|
|
D Focused Assessment
|
|
Biology
|
1 (0.4%)
|
|
Psychology
|
240 (100%)
|
|
Spiritual
|
235 (97.9%)
|
|
Cultural
|
212 (88.3%)
|
|
E Nursing Diagnosis
|
50 (20.8%)
|
|
F Discharge Planning
|
|
Identification during hospitalization
|
239 (99.6%)
|
|
Identification of requirements at home
|
99 (41.3%)
|
|
Quality of life
|
159 (66.3%)
|
|
G Education
|
237 (98.8%)
|
|
H Intervention
|
|
Vital signs intervention
|
213 (88.8%)
|
|
Other interventions
|
238 (99.2%)
|
|
Collaboration: Drug administration
|
146 (60.8%)
|
|
I Monitoring and Evaluation
|
|
Monitoring vital signs
|
56 (23.3%)
|
|
Monitoring activity of daily living
|
91 (37.9%)
|
|
Other monitoring
|
239 (99.6%)
|
|
J Mobilization/Rehabilitation
|
90 (37.5%)
|
|
K Outcome
|
112 (46.7%)
|
|
L Discharge Planning/Education
|
|
Nursing resumé
|
2 (0.8%)
|
|
Initial of nurse in charge
|
239 (99.6%)
|
