puffy1

I have to write a care plan for one of my patients. This is my first time and I really don't know what to look for. I have to go to the Medical Record department of the hospital to look at their medical record history. I am not really sure what I am to look for. The things needed on my lists are: Part I A. Summary of Impressions (2) B. Client Variables (overall depth and breath of information) 1. Physical (complete and attached (1) 2. Psychological (1) 3. Sociocultural (1) 4. Developmental (2) 5. Spiritual C. Client Stressors (3) (multiple stressors I.D. and discussed) D. Medications (3) Complete info. (classification/rationale/Nursing implications/effects on labs. Includes references. E. Diagnostic Tests (3) Complete info with references. I.D. reason that pt. lab results are abnormal by underlining cause. I.D. labs that should be ordered and states rationale. F. Medical Diagnosis/Surgical Procedures (3) Must be referenced. Includes Pathophysiologic template. Part II Focus sheets A. Nursing Diagnosis (5) Appropriateness of diagnosis. All S&S and R/F somewhere in care plan. B. STG/OC (5) Are OC measurable, specific, observable. C. Interventions (5) Treating the etiology Each OC addressed. I.D. primary, secondary, tertiary interventions. D. Rational (5) Each intervention has a related rational and each rational is referenced. E. Evaluation (5) Part III References (3) Part IV Overall Quality of Paper (2) Spelling, punctuation, attention to detail, organization, APA format. I know this is alot but can you offer any advice? Thanks soooo much!!