Exam (elaborations)

CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 3 CLINICAL COURSES PAGE 1 OF 10 CHAMBERLAIN UNIVERSITY

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ATI Fundamentals

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ATI Fundamentals

CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 3 CLINICAL COURSES PAGE 1 OF 10 CHAMBERLAIN UNIVERSITY National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | Please visit Student Name: D#: Date: Course: Session and Year: Directions ...

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Uploaded on January 4, 2024
Number of pages 10
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Type Exam (elaborations)
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clinical learning
clinical learning direct patient care documenta
clinical learning direct patient care

Institution ATI Fundamentals
Course ATI Fundamentals

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1-180405 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADACLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 3 CLINICAL COURSES
PAGE 1 OF 10
CHAMBERLAIN UNIVERSITY National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information.
Student Name: D#: Date: Course: Session and Year: 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 Due Drug/Classification Clinical Significance • 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. 2. 3. • 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 typed, Word document, Times New Roman 12-point font. Minimum of one page and no more than three pages.CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 3 CLINICAL COURSESCHAMBERLAIN UNIVERSITY National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information. 1-180405 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADACLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 3 CLINICAL COURSES
PAGE 2 OF 10
CHAMBERLAIN UNIVERSITY National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information.
I-SBAR
I
Introduce YourselfYour Name:
D#:
Your Title:
Reason for being there:
S
SituationPatient: Age:
Gender:
Height/Weight:
Race/Ethnicity:
Allergies:
Code Status:
Advance Directive (Durable Power of Attorney, Living Will, Other) & Clinical Significance: Privacy Code:
Date of Care/Time:Attending Physician: Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance:
Pathophysiology of Primary Medical Diagnosis:
B
Background**Include clinical significance with each** Past Medical History: Past Surgical History:
Social History/Socioeconomic Factors:
A
AssessmentVital Signs:
B/P HR RR TEMP SP02 PAIN
Falls risk: Accu check: IV Site: IV Fluids: Isolation Isolation Precautions N Y Contact Air Droplet
RESPIRATORY
CARDIOVASCULAR
NEUROLOGICAL
GI/GU I & O
INTEGUMENTARY
PSYCHOLOGICAL FAMILY - SUPPORT
SAFETY Teaching needed:
Quality in Safety Education Nurses (QSEN) Risk(s) Identified:
R
REQUEST/ RECOMMENDATIONHand off report to: From:

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