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Student Name: Date of Admission: CJSim Client Initials: Date of Care: Age/DOB: Admitting Diagnosis: Allergies: Comorbidities: BSA/BMI: Code Status: Planned Treatments/Procedures: Nursing and HCP Collaborative

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Student Name: Date of Admission: CJSim" Client Initials: Date of Care: Age/DOB: Admitting Diagnosis: Allergies: Comorbidities: BSA/BMI: Code Status: Planned Treatments/Procedures: Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider orders Cultural/Spiritual: Health Promotion/Development: Neurological/Cognition/Coping/Adaptation/Function: Infection/Immunity/Inflammation: Nutrition/Elimination: Mobility: Fluid/Electrolytes/Acid-Base: Pain/Comfort/Tissue Integrity: Gas Exchange/Perfusion: Safety: Glucose Regulation: Other

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