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1 INITIAL EVALUATION AND NURSING ASSESSMENT Patient Age Ethnicity Religion Marital Status Occupation Informant Reliability DIAGNOSES: (list all diagnoses, surgical procedures & complications HISTORY
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Initial evaluation and nursing refers to the initial assessment and care plan developed by a nurse for a patient upon admission to a healthcare facility.
Registered nurses or licensed practical nurses are required to perform and document the initial evaluation and nursing for each patient.
Initial evaluation and nursing should be filled out by documenting the patient's medical history, current condition, vital signs, medications, and care plan.
The purpose of initial evaluation and nursing is to assess the patient's health status, identify any immediate care needs, and develop a plan for ongoing care and treatment.
Information such as patient's medical history, current symptoms, vital signs, medication list, allergies, and nursing assessment findings must be reported on the initial evaluation and nursing form.
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