C H AMB ER LAIN U N I V E RS I T Y
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.
CLINICAL LEARNING – DIRECT
PATIENT CARE DOCUMENTATION
LEVEL 3 CLINICAL COURSES
PAGE 1 OF 10
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.
•A
ssessment 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:
–D
iagnostic 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.
– T herapeutic 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.
–M
edications: 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.
, C H AMB ER LAIN U N I V E RS I T Y
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.
CLINICAL LEARNING – DIRECT
PATIENT CARE DOCUMENTATION
LEVEL 3 CLINICAL COURSES
PAGE 2 OF 10
I-SBAR
Your Name:
I
D#:
Your Title:
Introduce Yourself
Reason for being there:
Patient: Attending Physician:
Age: Patient Chief Complaint/Primary Medical Diagnosis and Clinical
Gender: Significance:
Height/Weight:
Race/Ethnicity:
S Allergies:
Code Status:
Situation Advance Directive (Durable Power of Attorney, Living Will, Other) & Pathophysiology of Primary Medical Diagnosis:
Clinical Significance:
Privacy Code:
Date of Care/Time:
**Include clinical significance with each**
B
Past Medical History: Past Surgical History:
Background
Social History/Socioeconomic Factors:
Vital Signs:
B/P HR RR TEMP SP02 PAIN
A
Assessment
Falls risk: Accu check:
IV Site: IV Fluids:
Isolation Isolation Precautions N Y Contact Air Droplet
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