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Click 'Get Form' to open the Symptom Textbook Patient document in the editor.
Begin by filling in your personal information at the top of the form, including your name, date, and facility. Ensure all fields are completed accurately.
Proceed to the 'Present Illness' section. Document the date of admission, healthcare provider's name, and reason for admission as stated by the patient.
In the 'Health History' section, provide detailed information about allergies, tobacco and alcohol use, prior hospitalizations, and surgeries. Use bullet points for clarity.
For each mode (Self-Concept, Role Function, Interdependence), assess and record any deficits along with corresponding nursing diagnoses. Be specific in your descriptions.
Complete the 'Physiologic/Physical Mode' section by documenting vital signs and conducting a thorough physical assessment. Include findings from lab tests if applicable.
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