Running head: NAME OF CARE PLAN 1
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Title of Plan of Care
South University Online
NAME PLAN OF CARE 2
**Please delete this statement and anything in italics prior to submission to shorten the length
of your paper.
Patient Initials ______
Subjective Data: (Information the patient tells you regarding themselves: Biased Information):
Chief Compliant: (In patient’s exact words)
History of Present Illness: (Analysis of current problems in chronologic order using symptom
analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated
symptoms and treatments tried]).
PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major
medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history,
obstetric and history sexual history).
Significant Family History: (Includes family members and specific inheritable diseases).
Social History: (Includes home living situation, marital history, cultural background, health
habits, lifestyle/recreation, religious practices, educational background, occupational history,
financial security and family history of violence).
Review of Symptoms: (Review each body system – This section you should place POSITIVE for…
information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ;
ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:;
Neurological:; Endocrine:; Hematologic:; Psychologic: .
Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .
Physical Assessment Findings: (Includes full head to toe review)
Laboratory and Diagnostic Test Results: (Include result and interpretation.)
Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of
Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as
education and counseling provided).
NAME PLAN OF CARE 3