Nurs/nurl 3105 (IEN course)

Summer 2015

Patient Care Report

Nursing Student ______________________

Date of Care_________________________
Pt. Initials _________
Age _______
____________________________

Allergies

Room Number _____

Gender _____
Status__________________________

Code

Mobility __________
__________________

Isolation Precautions

Diet _______

Toileting __________
Assistive devices
_______________________________________
Admitting Diagnosis / Chief Complaint / Current Diagnosis/ Working Diagnosis

PATHOPHYSIOLOGY OF PRIMARY DIAGNOSIS

Pertinent Medical history

SCHEDULED PROCEDURES/TREATMENTS

Nurs/nurl 3105 (IEN course)

Summer 2015
VITAL SIGNS + Pain Assessment

Abnormal LAB VALUES

TEST

Pt. result

Date of lab draw ________________________

NORMAL
RANGE

INTERPRETATION - Your best reasoning as to why this

patient has this abnormal test result.

List all meds scheduled to be given during your shift.

List any PRN meds you administer.
INDICATION
MEDICATION
Nursing Considerations
scheduled
(why is your patient
Dose/Route
including. side effects r/t your patient
taking this med)

Nurs/nurl 3105 (IEN course)

Summer 2015

ASSESSMENTS by systems
NEUROLOGICAL

CARDIOVASCULAR

RESPIRATORY

GI ASSESSMENT

Last BM:

GU ASSESSMENT

MUSCULOSKELETAL ASSESSMENT

INTEGUMENTARY ASSESSMENT

PSYCHOSOCIAL ASSESSMENT

Nurs/nurl 3105 (IEN course)

Summer 2015
VASCULAR ACCESS (type, location, date inserted/changed; fluids running)

SAFETY / Special CONSIDERATIONS

NURSING CARE PLAN (ADPIE)

problems)
Problem #1
Assessment Data

Nursing Diagnoses

(focusing on one of the priority

Plan

Interventions

Evaluation

Patient will:
Goal:

NS will:
1)

1)

2)

2)

3)

3)

Outcomes:
1)
Related to

2)
As evidenced by

________________
3)

Nurs/nurl 3105 (IEN course)

Summer 2015

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)

Nurs/nurl 3105 (IEN course)

Summer 2015
Dominican University of California
CLINICAL EVALUATION Tool
The Student:
1. Does not meet Standard (DNS): Is not yet effective in assessing, observing, recognizing
patterns and deviations, or seeking information. Takes an unfocused approach to
collecting and organizing data and requires assistance in diagnosing actual or potential
nursing problems, planning interventions, carrying out skills, and evaluating outcomes.
Shows hesitance in communicating and responding to most clinical scenarios.
2. Meets Standards (MS): Captures obvious patterns, collects and interprets a variety of
data, but may overlook some important information. Performs basic assessment,
diagnostic, and clinical skills, but still requires some guidance and direction. Conducts
appropriate follow-up to evaluate the effectiveness of nursing interventions. Shows solid
foundation in leadership and communication abilities, though may be disorganized and
hesitant in some aspects of clinical situations.
3. Exceeds Standards (ES): Effectively assesses, seeks information, recognizes obvious
and more subtle patterns and deviations, and plans interventions. Displays confidence and
leadership ability, communicates effectively, and requires guidance only in complicated
cases. Demonstrates proficiency in most nursing skills, and requires minimal prompting
in responding to clinical scenarios Completes timely and effective evaluation of nursing
interventions, and develops and updated plan of care when the need for such
modifications have been recognized.

NURL 3105 CLINICAL EVALUATION

Student:
Semester:

DUC ID:

Agency:
Advisor:

Instructor:

DNS=Does Not Meet Standards (1)

*MS =Meets Standards (2)
ES = Exceeds Standards (3)
*By the end of the clinical rotation, the student must achieve MS (2), at a developing student
level to meet the requirement for passing.
NATIONAL,
PROGRAM, AND
COURSE
OUTCOMES
Integration of Care
DUC BSN Program
SLO #1
National BSN
Essential I
Nurl 3105 SLO:

CLINICAL PRACTICE
COMPETENCIES

Demonstrates integration of the

theory component of the Nurl3105
course into clinical nursing
practice

Mi
d
Ter
m

End
Ter
m

Comments

Nurs/nurl 3105 (IEN course)

Summer 2015
Demonstrate
developing
knowledge of key
concepts related to
medical-surgical
nursing, including
safety, infusion
therapy, gas
exchange,
metabolism, cardiac
output, elimination,
perfusion, and
nutrition.
Nursing Process
DUC BSN Program
SLO #2
National BSN
Essential II
Nurl 3105 SLO:
Utilize the nursing
process and assess
the effectiveness of
nursing care in
meeting the physical,
emotional, spiritual,
and social needs of
the adult patient in
acute care settings.

Incorporates learning from prior

nursing and non-nursing
coursework into clinical decision
making, psychomotor functioning,
and interpersonal encounters in
care of the acutely ill adult

Conducts an appropriate focused

(diagnoses-specific) assessment on
every patient receiving care in the
med/surg setting in a timely
manner
Correctly interprets assessment
data (including laboratory or other
diagnostic testing values)
Determines the priority nursing
problems (actual and potential) for
the patient
Begins planning care by
developing a list of appropriate,
individualized nursing
interventions
Discusses rationale for medical
and nursing orders and questions
orders if uncertain
Implements planned nursing
interventions and medically
ordered treatments on time, safely,
and accurately according to
standard facility protocols
Evaluates the effects of
interventions
Responds to changing patient
conditions

Patient Centered
Care
DUC BSN Program
SLO #3

Obtains information about the

patient prior to and during the

Nurs/nurl 3105 (IEN course)

Summer 2015
National BSN
Essential VIII
QSEN Competency:
Patient Centered
Care
Nurl 3105 SLO:
Apply compassionate
and ethical patientand family-centered
care while
communicating
respectfully to
individuals coming
from socio-culturally
diverse backgrounds

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.

Assesses the patients current

knowledge level, ability, and
readiness to learn, accounting for
the effects of culture, language,
cognitive ability, health condition,
and literacy
Provides effective instruction to
help patients acquire knowledge
and skills
Involves significant family
members in teaching-learning
activities whenever possible
Offers access to additional
resources for ongoing education
and reinforcement in the postdischarge period

Multi-disciplinary
Communication and
Collaboration
DUC BSN Program
SLO #5

Provides clear, concise patient

report to other members of the

Nurs/nurl 3105 (IEN course)

Summer 2015
National BSN
Essential VI
QSEN
Competencies:
Teamwork and
Collaboration;
Patient-Centered
Care
Nurl 3105 SLO:
Collaborate with
inter-professional
team members to
meet the specific
needs of patients and
their families as a
developing nursing
student.

healthcare team utilizing SBAR or

other organization standard
handoff tool
Discusses plan of care and with
appropriate staff nurse and clinical
instructor. Asserts own
perspective in patient care
discussions with team members
Provides on-going communication
with the staff nurse regarding any
identified changes in patient
condition
Participates in intraprofessional
team activities through
information-giving, participatory
decision-making, and, if
necessary, reporting any concerns
regarding patients status or care
Delegates appropriately to other
team members when assistance is
needed
Requests help from instructor or
relevant team member when in
doubt about any patient carerelated matter
Informs responsible staff nurse
and instructor prior to leaving the
patient care area
Documents patient assessment
data in a complete and timely
fashion and completes all required
documentation prior to leaving the
unit
Uses appropriate professional
language and tone when managing
conflict
Receives input or constructive
criticism from others without
defensive behaviors

Organizational
Systems, Leadership,
Quality
Improvement, and

Nurs/nurl 3105 (IEN course)

Summer 2015
Patient Safety
DUC BSN Program
SLOs #6
National BSN
Essentials II
QSEN Competency:
Quality
Improvement and
Safety
Nurl 3105 SLO:
Demonstrate
professionalism,
accountability, and
developing
competency
including leadership
and delegation skills
of the registered
nurse.

Participates in clinical conference

discussions showcasing
experiences of class members to
improve direct and indirect
learning from exposure to multiple
patient care encounters
Safety:
Surveys the patient care
environment to identify and acts to
remove potential safety hazards to
reduce the risk of patient, visitor,
and/or staff injury
Complies with the organizational
standards for safe med/surg
patient transport within and
between units
Demonstrates ability to provide
safe and effective care to multiple
patients or to 1 high acuity patient
Demonstrates ongoing accuracy
with safe medication and fluid
administration practices through
written and practical applications
including:
Demonstrates safe practices
related to medication
administration including: rights,
verification of allergies, two
patient identifiers, read-back
process, and independent double
checks for high-alert medications
Educates patient or patients agent
on safety practices when
administering medications.

Evidence-based
Practice
DUC BSN Program
SLO #10
National BSN
Essential IV
QSEN Competency:
Informatics
Nurl 3105 SLO:
Demonstrate

Accurately navigates the

electronic health record or printed
chart to locate and document
information
Verbalizes how the HIPAA
applies to computerized health
information systems and insures

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Nurs/nurl 3105 (IEN course)

Summer 2015
appropriate
competency as a
developing nursing
student with the
application of health
information
technology or
informatics in the
acute care setting.

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

confidentiality of protected health

information by following agency
protocols
Demonstrates accuracy in using
electronic medication
administration systems
Accesses and evaluates online
patient education materials,
policies and procedures,

Exemplifies the standards of the

ANA Code of Ethics including:
Demonstrating professional
integrity, honesty, respect for
persons, and accountability for
own actions
Assuring patient privacy and
confidentiality by accessing and
communicating patient
information within HIPAA
regulations
Providing patient-centered care
with sensitivity and respect for the
diversity of human experience and
the rights of patients and their
families in the adult acute care
setting
Exhibits professional conduct and
accountability by:
Arriving at the assigned clinical
shift on time and prepared to begin
work
Attending every assigned
clinical day
Dressing appropriately
according to DUC dress code
policy
Working within the role of a
nursing student according to DUC
and organizational guidelines
Independently seeking

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Nurs/nurl 3105 (IEN course)

Summer 2015
additional information or
resources to improve knowledge
and/or skill deficits
Managing multiple
responsibilities and completing
tasks within expected time frames
Using clinical time effectively
by seeking learning opportunities,
providing assistance to others, and
engaging in appropriate downtime activities
Showing initiative and selfdirection in selecting patients who
will provide unique learning
opportunities

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Nurs/nurl 3105 (IEN course)

Summer 2015
MIDTERM Comments:
Instructor:

Student:

Student Signature: ________________________ Date: _______

Faculty Signature: __________________________ Date: ________

Total Tardy Shifts:
Total Absent Shifts:

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Nurs/nurl 3105 (IEN course)

Summer 2015

ENDTERM Comments:
Instructor

Student

Student Signature: ________________________ Date: _______

Faculty Signature: __________________________ Date: ________

Total Tardy Shifts:
Total Absent Shifts:

14