Clinical Patient Clinical Judgement Concept Map

Choose one patient at clinical to complete a concept map. Paraphrase the patient’s history and physical data ensuring inclusion of the following information to create patient introduction data for the concept map:

History of Present Illness (HPI)

Age: In decades e.g 65 years should be 60s

Gender

Code status

Allergies

Isolation and precaution

VS on admission and date of care. Include POX and pain

Admitting diagnosis

Activity/Functional level

Bowel & Urinary elimination status

Skin integrity

Morse and Braden score

DVT prophylaxis

Labs: Na, K, a, C02, BUN, Creat, glucose, WBC, H/H, Platelet, PT, PTT, and INR

***Provide a minimum of 2 assessment data to support your top 3 prioritized problems

**** Look at the healthcare provider’s assessment and plan under H & P or progress note and patient care orders for assessment and interventions data.

*** If any of the above requested data is not available in your patient’s record, indicate unavailability Note posted concept map care plan guidelines and grading rubric.

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