DA Form 3888. Medical Record - Nursing History and Assessment
The DA Form 3888, known as the Medical Record - Nursing History and Assessment, is used to document the nursing history and assessment of patients in healthcare settings. This form is typically utilized by nurses or other healthcare professionals involved in patient care and treatment.
The form consists of sections that capture important information related to the nursing history and assessment. These sections include patient, medical history, current health status, nursing assessment findings, and care plans. The form provides fields for recording the patient's name, age, gender, and other identifying details.
When filling out the DA Form 3888, it is essential to gather accurate and comprehensive information about the patient. Patient identification details, such as name and date of birth, should be recorded correctly to ensure proper and avoid any confusion. The medical history section allows for documenting relevant past medical conditions, surgeries, allergies, and medications.
The current health status section provides space to record the patient's chief complaint, vital signs, symptoms, and any ongoing treatments or interventions. The nursing assessment findings section allows for documenting the nurse's observations, physical assessments, and subjective information provided by the patient.
The form also includes a care plan section where nursing interventions, goals, and expected outcomes are documented. This helps guide the nursing care provided to the patient and ensures continuity of care among different healthcare providers.
An example application of the DA Form 3888 would be in a hospital or clinic setting where nurses are responsible for assessing and managing patient care. By using this form, nurses can systematically document the patient's nursing history, perform assessments, and develop individualized care plans. The form serves as a tool for communication among healthcare providers, documentation of patient care, and monitoring of progress and outcomes.