Escolar Documentos
Profissional Documentos
Cultura Documentos
Summer 2015
Date of Care_________________________
Pt. Initials _________
Age _______
____________________________
Allergies
Code
Mobility __________
__________________
Isolation Precautions
Diet _______
Toileting __________
Assistive devices
_______________________________________
Admitting Diagnosis / Chief Complaint / Current Diagnosis/ Working Diagnosis
SCHEDULED PROCEDURES/TREATMENTS
Pt. result
ASSESSMENTS by systems
NEUROLOGICAL
CARDIOVASCULAR
RESPIRATORY
GI ASSESSMENT
Last BM:
GU ASSESSMENT
MUSCULOSKELETAL ASSESSMENT
INTEGUMENTARY ASSESSMENT
PSYCHOSOCIAL ASSESSMENT
Nursing Diagnoses
Plan
Interventions
Evaluation
Patient will:
Goal:
NS will:
1)
1)
2)
2)
3)
3)
Outcomes:
1)
Related to
2)
As evidenced by
________________
3)
Problem #2
Assessment Data
Nursing Diagnoses
Plan
Interventions
Evaluation
Patient will:
Goal:
NS will:
1)
1)
2)
2)
3)
3)
Outcomes:
1)
Related to
2)
As evidenced by
________________
3)
DUC ID:
Agency:
Advisor:
Instructor:
CLINICAL PRACTICE
COMPETENCIES
Mi
d
Ter
m
End
Ter
m
Comments
Patient Centered
Care
DUC BSN Program
SLO #3
period of care
Establishes and maintains
professional rapport with the
patient and the significant other(s)
using principles of therapeutic
communication
Conducts all nursing care with
consideration for patients rights
and cultural, spiritual, social,
cognitive, and physical conditions
Informs the patient about plan of
care, including any medications
prescribed or procedures to be
performed
Provides opportunities for patient
to discuss problems, or to raise
concerns about their care
Includes patient (and significant
others if desired by patient) in
individualized care planning
activities
Patient Education
DUC BSN Program
SLO #4
National BSN
Essential VII
QSEN Competency:
Patient Centered
Care
Nurl 3105 SLO:
Assess patient
learning needs and
provide primary,
secondary, and
tertiary education.
Multi-disciplinary
Communication and
Collaboration
DUC BSN Program
SLO #5
Organizational
Systems, Leadership,
Quality
Improvement, and
Evidence-based
Practice
DUC BSN Program
SLO #10
National BSN
Essential IV
QSEN Competency:
Informatics
Nurl 3105 SLO:
Demonstrate
10
Professional Values
and Ethical Conduct
DUC BSN Program
SLO #11
National BSN
Essential VIII
Nurl 3105 SLO:
Demonstrate
professional conduct
to provide a safe
environment in the
acute care setting in
order for patientcentered care to be
delivered
11
12
Student:
13
ENDTERM Comments:
Instructor
Student
14