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Running head: NAME OF CARE PLAN 1 Title of Plan of Care NameSouth University Online Faculty Name NSG 6001Date 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: . Objective Data:Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .Physical Assessment Findings: (Includes full head to toe review)HEENT:Lymph Nodes:Carotids:Lungs:Heart:Abdomen:Genital/Pelvic:Rectum:Extremities/Pulses:Neurologic: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 priority.) Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided). NAME PLAN OF CARE 3 References