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NUR 411 Direct Patient Care Document
- Course
- Nur 411
- Institution
- Borough Of Manhattan Community College
This document serves as a guideline for proper clinical care documentation. *An Essential Study Material?
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Clinical Learning – Direct Patient Care DocumentationClinical Learning – Direct Patient Care Documentation
Level 3 Clinical Courses
Level 3 Clinical Courses
Student Name: D#: Date: Egzona Krasniqi
Course: Session and Year: NR326 2021
DIRECTIONS
This Direct Patient Care Documentation must be completed for one patient whom you are providing direct care in a clinical learning
setting. All information within this packet must be handwritten, (with the exception of the reflection journal) reviewed with your faculty
on your assigned clinical day and submitted within 24 hours (or as directed by course coordinator). If additional space is needed,
please use the back of each page.
• 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, Labs and Healthcare Provider Orders: Document your initial and ongoing assessment findings, lab results with
why they were drawn specifically for your patient and healthcare provider orders with why they were specifically ordered for
your patient.
• ATI® Active Learning Templates Required:
– Diagnostic Procedure: Select one diagnostic procedure from the healthcare orders table and complete one Active Learning
Template: Diagnostic Procedure. The selected diagnostic procedure should be one in which you have not previously completed a
template for this session.
– Therapeutic Procedure: Select one therapeutic procedure from the healthcare orders table and complete one Active Learning
Template: Therapeutic Procedure. The selected therapeutic procedure should be one in which you have not previously completed
a template for this session.
– Nursing Skill: Select one nursing skill from the healthcare orders table and complete one Active Learning Template: Nursing Skill.
The selected nursing skill should be one in which you have not previously completed a template for this session. – Medications: List
medications below and complete one Active Learning Template: Medication for each medication classification in which you have not
previously completed a template.
Time 10mg PO dailyDrug/Classification Clinical Significance
Fluoxetine
No other meds
• Nursing Diagnosis:
Identify three nursing diagnoses for your patient and list them by priority below. Complete one concept map for your top nursing
diagnosis listed below.
1. Imbalanced nutrition: less than body requirements
2. Disturbed body image, chronic low self esteem
3. Disturbed thought process
• Reflection Journal:
, Complete a reflection journal and submit to your faculty 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. 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.
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Clinical Learning – Direct Patient Care Documentation
Level 3 Clinical Courses
I-SBAR
I – Introduce Yourself Your Name: Egzona Krasniqi
D#: D41056179
Your Title: nursing student
Reason for being there: patient care
S – Situation Patient: Jamie Johanson Attending Physician:
Age: 19 Patient Chief Complaint/Primary Medical Diagnosis
Gender: Female and Clinical Significance: pt is depressed, loss a lot of
Height/Weight: 5’4 weight, has a low BMI, nervosa anorexia
Race/Ethnicity: Caucasian
Allergies: none
Code Status: full
Advance Directive (durable power of attorney,
living will, other) and Clinical Significance: yes Pathophysiology of Primary Medical Diagnosis: anorexia
nervosa : does not eat, low BMI
Privacy Code:
Date of Care/Time: morning
B – Background Include clinical significance with each:
Past Medical History: Past Surgical History: anorexia nervosa
Social History/Socioeconomic Factors: is in college, is a waitress, single, has parents and 2 brothers
A – Assessment Vital Signs:
B/P HR RR TEMP SP02 PAIN
92/54, pulse 52, rr 16, temp 97.8, no pain
Falls risk: Accu-check: no fall risk
IV Site: IV Fluids: none
Isolation Isolation Precautions: Y N Contact: Air Droplet . No
RESPIRATORY No SOB, breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort
CARDIOVASCULAR Rate regular, bradycardic
NEUROLOGICAL a/o x4 CN IIXI- grossly intact, no sensory deficits, negative Romberg, normal gait
GI/GU GI- nontender, without masses, or organmegaly, normoactive bowel sounds throughout
I and O
INTEGUMENTARY Pale, dry skin, no rashes, erythema, or russells signs
PSYCHOLOGICAL Has parents, 2 brothers, is in college in dorm, and works as waitress, walks 4-5 miles a day
FAMILY – SUPPORT
SAFETY Sit with patient when meals come, monitor I&Os
Quality in Safety Education Nurses (QSEN) Risk(s) Identified:
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