lOMoARcPSD|44429024
(NR 324) PCD #3 - Patient care documentation
Adult Health I (Chamberlain University)
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, lOMoARcPSD|44429024
Clinical Learning - Direct Patient Care Documentation Pute 1 of 1
Level 3 Cl.nicalCourse5
CHAMBERL.IN CNIVERSITY
Student Name: D#: 413246T Date: O2423
Year:2023
Course: NE 324 Admt tleath Session:
DIRECTIONS
you are providing direct care in a clinical
This Direct Patient Care Documentation must be completed for one patient whom exception
padket must be handwritten, (with the of the reflection journal) reviewed
learning setting. All information within this hours (or as directed by course coordinator). If additional
with your faculty on your assigned clinical day and submitted within 24
space is needed, please use the back of each page.
evaluation.
Grading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the clinical learning
Satisfactory rating meets the following:
requirements successfully (PO 5).
-Clinical Learning Competency: Completes all clinical learning experiences and
within established guidelines.
"Perfomance Descriptor: Completes all assignments related to the clinical learning experience
"SBAR: Uilized for receiving report. Areas that indicate clinical significance are to be completed after patient report has been
of their shift to the bedside nurse.
received. Students should deliver a hand-off report at the end
initial and ongoing assessment findings, lab
" Assessment Findings, Labs and Healthcare Provider Orders: Document your
results with why they were drawnspecifically for your patient and healthcare provider orders with why they were specifically
ordered for your patient.
" ATP Active Leaming Termplates Required:
orders table and complete one Active Learning
- Diagnostic Procedure: Select one diagnostic procedure from the healthcare previously
which you have not
Template: Diagnostic Procedure. The selected diagnostic procedure should be one in
completed a termplate for this session.
and complete one Active Learning
-Therapeutic Procedure: Select one therapeutic procedure from the healthcare orders table
Template: Therapeutic Procedure. The selected therapeutic procedure should be one in which you have not previously
completed a template for this session.
Template: Nursing
Nursing skill: Select one nursing skill from the healthcare orders table and complete one Active Learning
this session.
Skill. The selected nursing sillshould be one in which you have not previously completed a template for
-Medications: List medications below and complete one Active Learning Template: Medication for each medication
classification inwhich you have not previously completed a template.
ame Dus Drug/Classificatlan Clinical Sigaificance
0900 Dulo xeHrne(SNP)30mg, tC Capule,po TXF0r anxiety/dePresAoD
0830 SUMArIptan (GSKA) Tnb hog Tx f0r mlgroin e/
TX for tremor
0900 So00 unH, INJM
Prevent Coaqula ton
0900
0900
Heparin(8Abuignt 60 mo, CAP ER,
Propranolol(36er) Zauy P0 daiy TX for ald retux
HTN - tx for hlgh BP
pahtoproa20le(PPI) 40HOme ECTab),
mo Medicaion
0900 Levothyroxle (Hormoner) 1?smcgs tab,P0 dQiy Tx for hypothyroidivm
.Nursing Diagnosis -ldehtitythree nursing diagnoses for your patient and list them by priority below. Complete one concept
map for your top nursing diagnosis listed below.
vC9nd redhdaminaL pan relate d
(00) hahds N a capillary retfill of t0 porphPhyria a/ evideh ce d by pat enf'r
3) Imp alrça mol lity related to Heak mMecles
rVideced by. Mhtady gart ond lower ettteolty rength o f r
"Reflection Joumal-Complete a reflection journal and submit to your faculty (or as directed) within 24 hours of completing
your clinical learning experience. Reflective journaling provides aformat 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.
Chamberln Unsersity | Nstonal Mansgernent 0lhces | S0 W. Monuoe SL Suta Z3| Chc 2go, lL OS1
12-194T o 2 Chamberlein Urversty LLC Al nghts reserved. 04Z2pilspeADA
Downloaded by KEVIN NJOROGE ()
(NR 324) PCD #3 - Patient care documentation
Adult Health I (Chamberlain University)
Scan to open on Studocu
Studocu is not sponsored or endorsed by any college or university
Downloaded by KEVIN NJOROGE ()
, lOMoARcPSD|44429024
Clinical Learning - Direct Patient Care Documentation Pute 1 of 1
Level 3 Cl.nicalCourse5
CHAMBERL.IN CNIVERSITY
Student Name: D#: 413246T Date: O2423
Year:2023
Course: NE 324 Admt tleath Session:
DIRECTIONS
you are providing direct care in a clinical
This Direct Patient Care Documentation must be completed for one patient whom exception
padket must be handwritten, (with the of the reflection journal) reviewed
learning setting. All information within this hours (or as directed by course coordinator). If additional
with your faculty on your assigned clinical day and submitted within 24
space is needed, please use the back of each page.
evaluation.
Grading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the clinical learning
Satisfactory rating meets the following:
requirements successfully (PO 5).
-Clinical Learning Competency: Completes all clinical learning experiences and
within established guidelines.
"Perfomance Descriptor: Completes all assignments related to the clinical learning experience
"SBAR: Uilized for receiving report. Areas that indicate clinical significance are to be completed after patient report has been
of their shift to the bedside nurse.
received. Students should deliver a hand-off report at the end
initial and ongoing assessment findings, lab
" Assessment Findings, Labs and Healthcare Provider Orders: Document your
results with why they were drawnspecifically for your patient and healthcare provider orders with why they were specifically
ordered for your patient.
" ATP Active Leaming Termplates Required:
orders table and complete one Active Learning
- Diagnostic Procedure: Select one diagnostic procedure from the healthcare previously
which you have not
Template: Diagnostic Procedure. The selected diagnostic procedure should be one in
completed a termplate for this session.
and complete one Active Learning
-Therapeutic Procedure: Select one therapeutic procedure from the healthcare orders table
Template: Therapeutic Procedure. The selected therapeutic procedure should be one in which you have not previously
completed a template for this session.
Template: Nursing
Nursing skill: Select one nursing skill from the healthcare orders table and complete one Active Learning
this session.
Skill. The selected nursing sillshould be one in which you have not previously completed a template for
-Medications: List medications below and complete one Active Learning Template: Medication for each medication
classification inwhich you have not previously completed a template.
ame Dus Drug/Classificatlan Clinical Sigaificance
0900 Dulo xeHrne(SNP)30mg, tC Capule,po TXF0r anxiety/dePresAoD
0830 SUMArIptan (GSKA) Tnb hog Tx f0r mlgroin e/
TX for tremor
0900 So00 unH, INJM
Prevent Coaqula ton
0900
0900
Heparin(8Abuignt 60 mo, CAP ER,
Propranolol(36er) Zauy P0 daiy TX for ald retux
HTN - tx for hlgh BP
pahtoproa20le(PPI) 40HOme ECTab),
mo Medicaion
0900 Levothyroxle (Hormoner) 1?smcgs tab,P0 dQiy Tx for hypothyroidivm
.Nursing Diagnosis -ldehtitythree nursing diagnoses for your patient and list them by priority below. Complete one concept
map for your top nursing diagnosis listed below.
vC9nd redhdaminaL pan relate d
(00) hahds N a capillary retfill of t0 porphPhyria a/ evideh ce d by pat enf'r
3) Imp alrça mol lity related to Heak mMecles
rVideced by. Mhtady gart ond lower ettteolty rength o f r
"Reflection Joumal-Complete a reflection journal and submit to your faculty (or as directed) within 24 hours of completing
your clinical learning experience. Reflective journaling provides aformat 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.
Chamberln Unsersity | Nstonal Mansgernent 0lhces | S0 W. Monuoe SL Suta Z3| Chc 2go, lL OS1
12-194T o 2 Chamberlein Urversty LLC Al nghts reserved. 04Z2pilspeADA
Downloaded by KEVIN NJOROGE ()
