Case Study Format

CASE STUDY FORMAT
I. HEALTH HISTORY
A. DEMOGRAPHIC (BIOGRAPHICAL) DATA

1. Client’s Name or Initial (Optional)
2. Gender (Sex)
3. Age, Birth date & Birthplace
4. Marital (Civil) Status
5. Race / Nationality
6. Religion
7. Address, Telephone Number (Include Contact of Client, i.e.: e-Mail Address)
8. Educational Background / Other Significant Training
9. Occupation (Usual and Present)
10. Usual Source of Medical Care
B. SOURCE AND RELIABILITY OF INFORMATION

➢ Sample Statements
➢ Client himself, who seems reliable
➢ Client’s Daughter, Son, or Nearest Kin, who seems reliable
➢ Other confidant, trusted friend, lawyer, etc., who seems reliable
C. REASON(S) FOR SEEKING CARE or CHIEF COMPLAINTS (Top 3)

(Problem with duration and accompanying s/s one or more symptoms or concerning using the patient to seek care or
may quotes the patients own words.)
Example:
✓ “Chest Pain” for 2 hours
✓ “Ear ache and restlessness all night”
✓ “Need yearly physical for work”
✓ “Want to start joggings and needs a check up”
D. HISTORY OF PRESENT ILLNESS / OR PRESENT HEALTH

(Complete clear and chronological account of the problems prompting to seek care, onset and manifestations reason
why patient sought consultation include medication taken.)
• Well Person : General State of Health
• Ill Person : (Chronological Story / Record)
Usual State of Health
8 Critical Characteristics
1. Timing (Frequency, Onset, Duration)
2. Location
3. Quality (Character)
4. Quantity (Severity)
5. Setting
6. Associated Phenomena / Factors
7. Aggravating & Alleviating Factors
8. Client’s Perception
E. PAST MEDICAL HISTORY OR PAST HEALTH

▪ Pediatric / Childhood / Adult Illness(es) (ex. Asthma)
▪ Injuries or Accident(s)
▪ Serious / Chronic Illnesses
▪ Hospitalization(s) (date)
▪ Operations (include year)
▪ Obstetric History (for female)
For Female Only
▪ Immunizations(s) (date)
▪ Allergies
▪ Medications (Prescribed and OTC Drugs) for 3 years & above
▪ Last Examination Date
F. FAMILY HISTORY (Family tree / or genogram / roster)

Female Male Client Deceased
F-SHS-130 (01-06-14) Case Study Format 1

G. SOCIO-ECONOMIC
H. DEVELOPMENTAL HISTORY
Select 1 Developmental Theory
I. REVIEW OF SYSTEMS (Refer to Guide)

Include the Date of Assessment and Assessment via IPPA
1. Regional Examinations
Presence or absence be used as noted. Date________
2nd Year- indicate findings using descriptive form.
3rd & 4th Year- indicate findings using bullet form. Brief and concise and utilize IPPA
Techniques
System
Physical examination (date & time)
a. General / Overall Health State
Anthropometric Measurements:
b. I P. Integument
(For Pedia 0-3 yrs. old.)
c. I P. Head
d. I P. Eyes
Ht. HC
e. I P. Ears
Actual wt CC
f. I P. Nose & Sinuses
V/S AC
g. I P. Mouth &Throat
Temp. Actual wt.
h. I P. Neck
PR IBW
i. I P. Breast & Axially
RR
j. I P. Respiratory
BP
k. I P. Cardiovascular
l. I P. Urinary
m. I P. Genitalia
n. I P. Musculoskeletal
o. I P. Neurological
p. I P. Hematological
q. I P. Endocrine
2. LABORATORY STUDIES / DIAGNOSTICS

Procedure Indication Normal Actual Nursing Responsibilities Significance/interpretation
Date Values Findings /Implications (PRE, Explanation of the findings
/Findings INTRA, POST) (as to high or low)
3. OTHER ASSESSMENT TOOLS (Scale, Sheet, Grade, Level etc.)

Date(s) Taken Comprehensive Actual Actual Result
Content /Legend
J. FUNCTIONAL ASSESSMENT (for 3 years old & above)
1. Health Perception /Health Management Pattern

2. Self-Esteem, Self Concept /Self Perception Pattern
3. Activity /Exercise Pattern
4. Sleep /Rest Pattern
5. Cognitive Perception
6. Nutrition
7. Elimination
8. Sexuality/reproductive
9. Interpersonal Relationships /Resources
10. Coping & Stress management / Tolerance Pattern
11. Values/Beliefs
K. PERSONAL/SOCIAL HISTORY
Habits
Vices
Lifestyle
Social Affiliation
Clients usual dislike
Rank/Order in the family

Travel
L. ENVIRONMENT HISTORY ( living/neighborhood circumstances)
M. OB GYNE HISTORY
For females only
OB Gyne history
menarche (age):__________ When____________

Amount and Characteristics
Duration
Associated Symptoms
N. PEDIATRIC HISTORY
Maternal and Birth history
Birthdate : Hospital:
BW
Type of Delivery
Condition After Birth
Mother:
Complications of Delivery
Anesthesia during labor
Exposure to Teratogenic agents during pregnancy
O. NEONATES ONLY
Neonatal History
Feeding History
Type of Feeding
I. PATHOPHYSIOLOGY Paradigm & Narrative Format

• Present Both Textual & Actual Symptoms & Signs
• Use Legends & Color Coding
Example:
Circle = Diagnostics / Laboratory Results
Triangle = Signs / Symptoms (Clinical Manifestations)
(Highlight / Color the S/S Seen / Present in the Patient)
Square = Precipitating Factors
Rectangle = Sequence of Events
II. CONCEPT MAPPING
III. PROBLEM LIST
a. ACTUAL or Active
Problem No. Problem Remarks
As Prioritized
b. HIGH RISK or Potential

Problem No. Problem Remarks
IV. NURSING CARE PLAN

CUES NURSING RATIONALE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS BACKGROUND
KNOWLEDGE

“S” ND: Prob. + SMART }PDx *Be Brief & Basis
O Cause if Known (Diagnosis) Concise /Supporting
-P.E. P >PRx Based from Data
Lab / dx E (Therapeutic) the book
(Head to S -Independent indicate the
Toe) -Interdependent book, author
15 -Dependent page/year
assessment PEd
(Education /Health
Teachings)
V. MEDICAL- SURGICAL MANAGEMENT (Curative)
i. Procedure (USN, Gavage, CTT, Surgery, Etc)

Procedure / Date Indication / Analysis Nursing Responsibilities
/Implications
(PRE, INTRA, POST)
ii. Pharmacotherapheutics / Medicines (IV Fluids, Drugs)

GN (BN) Indication MECHANISM OF SIDE EFFECT Nursing
Classification (Client Specific) ACTION ADVERSE Responsibilities
Stock Dosage & Frequency REACTIONS includes health
teaching and
Implications
(PRE, INTRA,
POST)
VII. DISCHARGE HEALTH TEACHINGS

Content Strategy
1. Compliance
M- Medication
E- Exercise
T- Treatment
H- Healthy Teaching
O- OPD
D- Diet
S- Signs & Symptoms
2. Follow up /Check-up
VIII. ON GOING APPRAISAL

A Comprehensive summary of patient’s health status to include medications,
procedures, Laboratory done in collaboration with other members of the HCT.

Case Study Format

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CASE STUDY FORMAT

A. DEMOGRAPHIC (BIOGRAPHICAL) DATA

B. SOURCE AND RELIABILITY OF INFORMATION

C. REASON(S) FOR SEEKING CARE or CHIEF COMPLAINTS (Top 3)

D. HISTORY OF PRESENT ILLNESS / OR PRESENT HEALTH

E. PAST MEDICAL HISTORY OR PAST HEALTH

F. FAMILY HISTORY (Family tree / or genogram / roster)

F-SHS-130 (01-06-14) Case Study Format 1

I. REVIEW OF SYSTEMS (Refer to Guide)

2. LABORATORY STUDIES / DIAGNOSTICS

3. OTHER ASSESSMENT TOOLS (Scale, Sheet, Grade, Level etc.)

J. FUNCTIONAL ASSESSMENT (for 3 years old & above)

1. Health Perception /Health Management Pattern

F-SHS-130 (01-06-14) Case Study Format 2

L. ENVIRONMENT HISTORY ( living/neighborhood circumstances)

menarche (age):__________ When____________

I. PATHOPHYSIOLOGY Paradigm & Narrative Format

II. CONCEPT MAPPING

III. PROBLEM LIST

b. HIGH RISK or Potential

IV. NURSING CARE PLAN

F-SHS-130 (01-06-14) Case Study Format 3

V. MEDICAL- SURGICAL MANAGEMENT (Curative)

i. Procedure (USN, Gavage, CTT, Surgery, Etc)

ii. Pharmacotherapheutics / Medicines (IV Fluids, Drugs)

VII. DISCHARGE HEALTH TEACHINGS

VIII. ON GOING APPRAISAL

F-SHS-130 (01-06-14) Case Study Format 4

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menarche (age): When__