patient care documentation

Clinical Learning – Direct Patient Care Documentation Level 4 Clinical Courses Page 1 of 10 Student Name: D#: Date: Course: Session: Year: DIRECTIONS This Direct Patient Care Documentation must be completed for one patient whom you are providing direct care in a clinical learning setting. Information within this packet can be handwritten or typed (with the exception of the reflection journal) and must be reviewed with your faculty on your assigned clinical day and submitted within 24 hours (or as directed by course leader). If additional space is needed, please use the back of each page. If any area within this packet was not performed, line out and place “N/A” in that section. • Grading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the Clinical Learning Evaluation. Satisfactory rating meets the following: – Clinical Learning Competency: Completes all clinical learning experiences and requirements successfully (PO 5). • Performance Descriptor: Completes all assignments related to the clinical learning experience within established guidelines. • Patient Report: Utilized for receiving report. Students should deliver a hand-off report at the end of their shift to the bedside nurse. • Assessment Findings, Nursing Notes, Labs/Diagnostics, and Healthcare Provider Orders: Complete according to your assigned patient. • Medication Information: List and complete the information for each medication your patient is ordered. • Clinical Judgment Measurement Model (CJMM): Complete reflecting on all the data/cues (Assessment, Labs/Diagnostics, Prescriptions/Orders and Patient Information) from your assigned patient. • Concept Map: Complete reflecting on all the information and assessment findings gathered from your assigned patient. • Reflection Journal – Complete a reflection journal and submit to your faculty (or as directed) within 24 hours of completing your clinical learning experience. Reflective journaling provides a format to share your knowledge, skills, experiences and personal reflection related to concepts and strategies learned throughout your program. What could you or did you delegate and to whom? Include ways you plan to care for yourself throughout your program. The reflection journal is required to be typed, Word document, Times New Roman 12-point font. Minimum of one page and no more than three pages. At least one time during the session, faculty will select one of the following questions for you to reflect on. 1. Describe how racial/health disparities, health equality/inequality, and social justice/injustice could apply to the clinical site/agency’s community. Consider the population and determine why this may be occurring. 2. Transportation and housing are drivers of health and equity. Describe the steps you would take as a nurse to evaluate transportation and housing for your identified community population and what actions you could perform to identify resources. 3. How can nurses be change agents and advocate for their community? Provide at least two specific examples. Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661 12-180406.3 ©2023 Chamberlain University LLC. All rights reserved. 0723pflcpe Clinical Learning – Direct Patient Care Documentation Level 4 Clinical Courses Page 2 of 10 Patient Report & Information Patient: Allergies: Age/Gender/Identity: Height/Weight: Patient Report & Information Provider: Primary Diagnosis: Patient: Allergies: Age/Gender/Identity: Code Status/Advance Directive: Height/Weight: Chief Complaint: Provider: Primary Diagnosis: Code Status/Advance Directive: Chief Complaint: PMH/PSH: VS: IV: PMH/PSH: VS: IV: Neuro: Cardio: Resp: Neuro: Cardio: Resp: GI/GU: Skin: Psych: GI/GU: Skin: Psych: Social History/Socioeconomic Factors/Psychological/Family Support: Social History/Socioeconomic Factors/Psychological/Family Support: Risks/Safety: Risks/Safety: Tests/Labs: Tests/Labs: Meds: Meds: Transfer/Discharge: Transfer/Discharge: Patient Report & Information Patient: Allergies: Age/Gender/Identity: Height/Weight: Patient Report & Information Provider: Primary Diagnosis: Patient: Allergies: Age/Gender/Identity: Code Status/Advance Directive: Height/Weight: Chief Complaint: Provider: Primary Diagnosis: Code Status/Advance Directive: Chief Complaint: PMH/PSH: VS: IV: PMH/PSH: VS: IV: Neuro: Cardio: Resp: Neuro: Cardio: Resp: GI/GU: Skin: Psych: GI/GU: Skin: Psych: Social History/Socioeconomic Factors/Psychological/Family Support: Social History/Socioeconomic Factors/Psychological/Family Support: Risks/Safety: Risks/Safety: Tests/Labs: Tests/Labs: Meds: Meds: Transfer/Discharge: Transfer/Discharge: Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661 12-180406.3 ©2023 Chamberlain University LLC. All rights reserved. 0723pflcpe Clinical Learning – Direct Patient Care Documentation Level 4 Clinical Courses Page 3 of 10 Initial Assessment Findings & Time Ongoing Assessment Findings & Time Vital signs: T: P: Resp: Sp02: BP: Height: Weight: Apical HR: Intake: Output: Pain scale used with rationale: O (Onset): Did your pain start suddenly or gradually get worse? Vital signs: T: P: Resp: Sp02: BP: Height: Weight: Apical HR: Intake: Output: Pain scale used with rationale: O (Onset): Did your pain start suddenly or gradually get worse? P (Palliative, Provocative) What makes the pain better/worse? P (Palliative, Provocative) What makes the pain better/worse? Q (Quality) How is the pain described? Q (Quality) How is the pain described? R (Radiation) Does the pain travel or spread anywhere else? If so, where? R (Radiation) Does the pain travel or spread anywhere else? If so, where? S (Severity) What is the intensity of the pain? S (Severity) What is the intensity of the pain? T (Temporal) Is the pain constant or does it come and go? T (Temporal) Is the pain constant or does it come and go? Head and neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea): Head and neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea): Respiratory (lung sounds, breathing effort, accessory muscles): Respiratory (lung sounds, breathing effort, accessory muscles): Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm): Abdomen (inspection, bowel sounds, palpation, contour): Abdomen (inspection, bowel sounds, palpation, contour): Bowel incontinence: Bowel plan: Last BM: Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): Bowel incontinence: Bowel plan: Last BM: Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities): Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities): Genitourinary (burning with urination, frequency, color of urine): Genitourinary (burning with urination, frequency, color of urine): Urinary incontinence: Urinary incontinence: Toileting plan: Toileting plan: Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.): Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.): Abuse screen (physical, elderly, child, sexual, etc.): Abuse screen (physical, elderly, child, sexual, etc.): IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type of IV fluid, assessment of IV site, last dressing change): IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type of IV fluid, assessment of IV site, last dressing change): Psychological/Psychosocial/Family Support/Religious/ Cultural Dynamics: Psychological/Psychosocial/Family Support/Religious/ Cultural Dynamics: Growth and Development: (Developmental stage according to Erikson and your assessment findings): Growth and Development: (Developmental stage according to Erikson and your assessment findings): Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661 12-180406.3 ©2023 Chamberlain University LLC. All rights reserved. 0723pflcpe Clinical Learning – Direct Patient Care Documentation Level 4 Clinical Courses Page 4 of 10 NURSING NOTES Date/Time Nursing Note Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661 12-180406.3 ©2023 Chamberlain University LLC. All rights reserved. 0723pflcpe Clinical Learning – Direct Patient Care Documentation Level 4 Clinical Courses Page 5 of 10 Telemetry Rhythm Strip If applicable: Attach your patient’s rhythm strip below and determine the following information: PRI: QRS: QT: Rate: Rhythm: What assessment findings/cues are associated with your patient’s rhythm? Identify the priority treatment based on your assessment findings (cues) and how you would evaluate for effectiveness. LABS & DIAGNOSTICS Test Result/ Date Norm Reason out of norm/reason for drawing if normal or N/A if not drawn Test WBC Glu RBC BUN Hgb Na Hct K Plt Cl Chol Creat Trig CO2 LDH Ca PT Phos APTT Mag AST T. Pro ALT Alb Tdl* Tdl* Result/ Date Norm Reason out of norm/reason for drawing if normal or N/A if not drawn What patient findings and interventions would you anticipate with these laboratory/diagnostic findings? * Therapeutic drug level Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661 12-180406.3 ©2023 Chamberlain University LLC. All rights reserved. 0723pflcpe Clinical Learning – Direct Patient Care Documentation Level 4 Clinical Courses Page 6 of 10 HEALTHCARE PROVIDER PRESCRIPTIONS (ORDERS) Items Order/ Frequency Priority (prioritize in the order you would perform) Reason (Explain specifically why ordered for this patient, potential complications, anticipated interventions and teaching required) Diet I/O VS Activity Accu-check Foley NG tube PEG tube PEJ tube Chest tube Trach Suctioning Drains Ostomy Dressing change and/or wound care Treatments Restraints Safety devices Special equipment Other Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661 12-180406.3 ©2023 Chamberlain University LLC. All rights reserved. 0723pflcpe Clinical Learning – Direct Patient Care Documentation Level 4 Clinical Courses Page 7 of 10 THE CLINICAL JUDGMENT MEASUREMENT MODEL The Clinical Judgment Measurement Model (CJMM) identifies six cognitive skills needed to make appropriate clinical judgments. Complete the following section using the CJMM and reflecting on all the data/cues (Assessment, Labs/Diagnostics, Prescriptions/Orders and Patient Information) from your assigned patient. ASSESSMENT RECOGNIZE CUES ANALYSIS ANALYZE CUES PRIORITIZE HYPOTHESIS PLANNING IMPLEMENTATION EVALUATION GENERATE SOLUTIONS TAKE ACTION EVALUATE OUTCOMES Recognize Cues – Identify relevant and important information from different sources (e.g., medical history, vital signs). Significant Data/Cue 1 Significant Data/Cue 2 Significant Data/Cue 3 Significant Data/Cue 4 Significant Data/Cue 5 List the data/cues that are relevant and are interpreted as clinically significant. Analyze Cues – Organizing and linking the recognized cues to the patient’s clinical presentation. Interpret the relevant clinical data/cues. Identify the top three most likely problems. Is additional data needed to confirm the clinical significance of the cues at this point? Be specific; what additional data is needed to confirm? Potential Problem 1 Potential Problem 2 Potential Problem 3 Additional Data Additional Data Additional Data Prioritize Hypothesis – Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk, difficulty, time, etc.). Of the potential problems you identified, which problem(s) is most likely present? Which problem is the most concerning and why? Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661 12-180406.3 ©2023 Chamberlain University LLC. All rights reserved. 0723pflcpe Clinical Learning – Direct Patient Care Documentation Level 4 Clinical Courses Page 8 of 10 Generate Solutions – Identifying expected outcomes and using hypotheses to define a set of interventions for the expected outcomes. Based on the most urgent problem, what are the priority actions/interventions? For each priority action, what are the desired outcomes? Priority Action/Intervention 1 Priority Action/Intervention 2 Priority Action/Intervention 3 Expected Outcomes Expected Outcomes Expected Outcomes Are there any interventions or actions that should be avoided? Include rationale. Take Action – Implementing the solution(s) that addresses the highest priorities. How should the interventions or actions above be accomplished? (Performed, administered, requested, communicated, taught, documented, etc.). List environmental and/or individual factors impacting the ability of the nurse to generate solutions and take action. Environmental Factor 1 Individual Factor 1 Environmental Factor 2 Individual Factor 2 Environmental Factor 3 Individual Factor 3 Evaluate Outcomes – Comparing observed outcomes against expected outcomes. Compare observed outcomes to expected outcomes – has the patient’s status improved, declined or remain unchanged? Observed Outcomes Observed Outcomes Observed Outcomes Does the observed outcome match expected outcome? If not, what are the additional actions/interventions that should be considered? Matches Expected Outcome? Matches Expected Outcome? Matches Expected Outcome? Environmental Factor 1 Environmental Factor 2 Environmental Factor 3 If the patient status has not improved, what other issues may be present? List environmental and/or individual factors impacting the achievement of outcomes. Individual Factor 1 Individual Factor 2 Individual Factor 3 Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661 12-180406.3 ©2023 Chamberlain University LLC. All rights reserved. 0723pflcpe Clinical Learning – Direct Patient Care Documentation Level 4 Clinical Courses Page 9 of 10 CONCEPT MAP Student Name: Date: Priority (Top 3) Interventions, Rationales and Education to Perform for Nursing Diagnosis Priority (Top 3) Information/Findings/ Signs and Symptoms (Cues) Priority (Top 3) Lab Values/Diagnostic Results Related to Nursing Diagnosis Potential and Actual Complications (Include dietary risk factors) Nursing Diagnosis Priority (Top 3) Contributing Social Determinants of Health (SDOH)/ Healthcare Disparities Factors Priority (Top 3) Patient Outcomes and Actions to evaluate the Outcomes Priority (Top 3) Medication(s) and Patient Teaching r/t Diagnosis. (Include medication side effects and nursing interventions for each) Priority (Top 3) Discharge Instructions and Evaluation of Effectiveness of Teaching (Include resources to mitigate SDOH and healthcare disparities. Include teach/back and/or verbalized understanding) Identify how the Four Spheres of Care (AACN, 2019) were addressed while caring for your patient. If a sphere is not applicable, provide rationale and/or exploration of how this could be incorporated into care. 1. Wellness, Disease Prevention (includes physical and mental health needs). 2. Chronic Disease Management (includes managing chronic disease and preventing further complications). 3. Regenerative/Restorative Care (includes complex acute, trauma and critical care and acute exacerbations of chronic conditions). 4. Hospice/Palliative Care (includes end of live care and supportive care for complex diseases and/or rehabilitative care). Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661 12-180406.3 ©2023 Chamberlain University LLC. All rights reserved. 0723pflcpe Clinical Learning – Direct Patient Care Documentation Level 4 Clinical Courses Page 10 of 10 MEDICATION INFORMATION Med Rec Completed: Y ☐ Med Name N☐ Med Classification Rationale for Med Home, Current, or New Med Time Due Contraindications/ Interactions Nursing Complications, Interventions & Considerations Patient Education Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661 12-180406.3 ©2023 Chamberlain University LLC. All rights reserved. 0723pflcpe

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