September 27, 2023

injustice could apply to the clinical

Clinical Learning – Direct Patient Care Documentation Level 2 Clinical Courses Page 1 of 10

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

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.

• I-SBAR: Utilized for receiving report. Areas that indicate clinical significance are to be completed after patient report has been

received. 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 a typed Word document,

Times New Roman 12-point font and 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.

Clinical Learning – Direct Patient Care Documentation Level 2 Clinical Courses Page 2 of 10

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

I-SBAR

I – Introduce Yourself

Your Name:

D#:

Your Title:

Reason for being there:

S – Situation

Patient: Attending Physician:

Age: Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance: Gender/Identity:

Height/Weight:

Allergies:

Code Status:

Advance Directive (durable power of attorney, living will, other) and Clinical Significance:

Pathophysiology of Primary Medical Diagnosis:

Privacy Code:

Date of Care/Time:

B – Background

Include clinical significance with each:

Past Medical History: Past Surgical History:

Immunizations Received:

Social History/Socioeconomic Factors:

A – Assessment

Vital Signs:

B/P HR RR TEMP SP02 PAIN

Fall Risk: Accu-check:

IV Site: IV Fluids: Lab/Test Results:

I and O

Isolation Isolation Precautions: Y ☐ N ☐ Contact Air ☐ Droplet ☐

RESPIRATORY

CARDIOVASCULAR

NEUROLOGICAL

GI/GU

INTEGUMENTARY

PSYCHOLOGICAL FAMILY – SUPPORT

SAFETY Teaching needed:

Quality in Safety Education Nurses (QSEN) Risk(s) Identified:

R – REQUEST/ RECOMMENDATION

Hand off report to: From:

Clinical Learning – Direct Patient Care Documentation Level 2 Clinical Courses Page 3 of 10

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

Initial 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? P (Palliative, Provocative) What makes the pain better/worse? Q (Quality) How is the pain described? R (Radiation) Does the pain travel or spread anywhere else? If so, where? S (Severity) What is the intensity of the pain? 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):

Respiratory (lung sounds, breathing effort, accessory muscles):

Cardiovascular (jugular vein, carotid arteries, cardiac sounds,

cardiac rhythm):

Abdomen (inspection, bowel sounds, palpation, contour):

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):

Genitourinary (burning with urination, frequency, color of urine):

Urinary incontinence: Toileting plan:

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.):

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:

Growth and Development: (Developmental stage according

to Erikson and your assessment findings):

Ongoing Assessment Findings & Time

Vital signs:

T: P: Resp: Sp02:

BP: Height: Weight: Apical HR:

Intake: Output:

Pain scale used with rationale:

Head and neck (inspect and palpate scalp, hair and skull,

facial expression/symmetry, trachea):

Respiratory (lung sounds, breathing effort, accessory muscles):

Cardiovascular (jugular vein, carotid arteries, cardiac sounds,

cardiac rhythm):

Abdomen (inspection, bowel sounds, palpation, contour):

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):

Genitourinary (burning with urination, frequency, color of urine):

Urinary incontinence: Toileting plan:

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.):

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:

Growth and Development: (Developmental stage according

to Erikson and your assessment findings):

Clinical Learning – Direct Patient Care Documentation Level 2 Clinical Courses Page 4 of 10

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

NURSING NOTES

Date/Time Nursing Note

Clinical Learning – Direct Patient Care Documentation Level 2 Clinical Courses Page 5 of 10

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

LABS & DIAGNOSTICS

Test Result/ Date

Norm Reason out of norm/reason for drawing if normal or N/A if not drawn

WBC

RBC

Hgb

Hct

Plt

Chol

Trig

LDH

APTT

AST

ALT

Tdl*

Test Result/ Date

Norm Reason out of norm/reason for drawing if normal or N/A if not drawn

Glu

BUN

Creat

CO2

Phos

Mag

T. Pro

Alb

Tdl*

What patient findings and interventions would you anticipate with these laboratory/diagnostic findings?

* Therapeutic drug level

Clinical Learning – Direct Patient Care Documentation Level 2 Clinical Courses Page 6 of 10

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

HEALTHCARE PROVIDER PRESCRIPTIONS (ORDERS)

Items Order/ Frequency

Prioritization (Prioritize the healthcare provider prescriptions (orders) based on your assessment cues)

Reason (Explain specifically why ordered for this patient, potential complications, anticipated interventions and teaching required)

Diet

I/O

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

Clinical Learning – Direct Patient Care Documentation Level 2 Clinical Courses Page 7 of 10

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

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.

RECOGNIZE

CUES

ANALYZE

CUES

PRIORITIZE

HYPOTHESIS

GENERATE

SOLUTIONS

TAKE

ACTION

EVALUATE

OUTCOMES

Recognize Cues – Identify relevant and important information from different sources (e.g., medical history, vital signs).

List the data/cues that are relevant and are interpreted as clinically significant.

Significant Significant Significant Significant Significant

Data/Cue 1 Data/Cue 2 Data/Cue 3 Data/Cue 4 Data/Cue 5

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?

ASSESSMENT ANALYSIS PLANNING IMPLEMENTATION EVALUATION

Clinical Learning – Direct Patient Care Documentation Level 2 Clinical Courses Page 8 of 10

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

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?

Does the observed outcome match expected outcome? If not, what are the additional actions/interventions that should be considered?

Observed Outcomes Observed Outcomes Observed Outcomes

Matches Expected Outcome? Matches Expected Outcome? Matches Expected Outcome?

If the patient status has not improved, what other issues may be present?

List environmental and/or individual factors impacting the achievement of outcomes.

Environmental

Factor 1

Individual

Factor 1

Environmental

Factor 2

Individual

Factor 2

Environmental

Factor 3

Individual

Factor 3

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

0723pflcpe

Clinical Learning – Direct Patient Care Documentation Level 2 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)

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).

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)

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

0723pflcpe

Clinical Learning – Direct Patient Care Documentation Level 2 Clinical Courses Page 10 of 10

MEDICATION INFORMATION

Med Rec Completed: Y ☐ N ☐

Med Name Med Classification Rationale for Med

Home, Current, or New Med

Time Due

Contraindications/ Interactions

Nursing Complications, Interventions & Considerations

Patient Education

DIRECTIONS

NURSING NOTES

HEALTHCARE PROVIDER PRESCRIPTIONS (ORDERS)

CONCEPT MAP

MEDICATION INFORMATION

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Describe how racial/health disparities, health equality/inequality, and social justice/injustice could apply to the clinical

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