BROKENSHIRE COLLEGE

Madapo, Hills, Davao City

DRUG STUDY
Name of Patient:____________________________________________ Age:________ Sex:_________ Civil Status:____________ Religion:________________________
Chief Complaint/Reason for Admission:__________________________________________________________________________________________________________________
Date & Time of Admission:_____________________________________________ Accompanied By/Informant:_______________________________________
Medical Diagnosis/ Impression:__________________________________________ Operation Performed (if any):______________________________________
GENERIC BRAND GENERAL MECHANISM OF ROUTE OF INDICATIONS CONTRAINDICATIONS ADVERSE REACTION/S NURSING RESPONSIBILITY
NAME NAME CLASSIFICATION ACTION DOSAGE

Submitted by:______________________________________________________ Clinical Instructor:_______________________________________________

Year & level:_______________________ Date Submitted:_________________________
 BROKENSHIRE COLLEGE
Madapo, Hills, Davao City
Nursing Care Plan
Name of Patient:______________________________________________ Age:______ Status:________ Room/Bed no.:________________________________
Chief Complaint/Reason for Admission:___________________________________________________________________________________________________________________________
Date & Time of Admission:_____________________________________________________________ Accompanied by/Informant:__________________________________
Medical Diagnosis/Impression:__________________________________________________________________________________________________________________________________
Operation Performed (if Any):___________________________________________________________ Date & Time:______________________________________________
Attending Physicians or Surgeon:________________________________________________________________________________________________________________________________
Date & Time of Assessment:____________________________________________________________ Date & Time of Evaluation:__________________________________
Cues & Evidences Nursing Diagnosis Objectives Nursing Interventions Rationale Evaluation

Submitted by:______________________________________________________ Clinical Instructor:_______________________________________________

Date:_______________________ Reference:_________________________