Clinical Paperwork Packet PDF PDF

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Clinical Paperwork Packet

Clinical Paperwork Packet Within this packet you will find the following: 1. 2. 3. 4. 5.

A head-to-toe assessment template A care plan template A laboratory values template A pharmacology drug card template (six pages) A care plan rubric

As part of the clinical experience, the student will be responsible for completing 2 of these packets. The packets must be completed on 2 different patients and are due no later than week 9 of the term. The head-to-toe assessment must be complete. Do not skip any of the sections. If a section does not apply, please write n/a (ex: patient does not have an IV site). Specifically, regarding the care plan, you must have 3 pieces of subjective information and 3 pieces of objective information. You must also have 2 goals/outcomes that meet the SMART acronym guidelines. You must have 3 interventions for each goal/outcome. All interventions must be relevant and include rationales. Your evaluation must state whether the goal was MET, NOT MET, or ONGOING and a brief statement as to why. Please provide information on all laboratory testing that was ordered on your patient. Please complete all 6 drug cards in this packet. This means you will need to provide information on 6 different drugs/classifications. (Ex: anti-hypertensives, antiemetics, benzodiazepines, etc.)

All sections of this packet must be completed prior to submission.

Revised 6.25.19

Clinical Paperwork Packet

Head to Toe Physical Assessment POLST/Code Status

VS

7:30

Temperature

Pulse

Respirations

BP

/

Pain

/10

VS

11:30 Temperature

Pulse

Respirations

BP

/

Pain

/10

GENERAL SURVEY Age___________ How does the client look?

Male/Female

Body Build: Thin

Height___________ Weight____________ Facial Expression: Anxious

Happy

Alert

Obtunded

Cachectic

Obese

Well groomed

Sad

WNL

Poorly Groomed

Angry

NEUROLOGICAL Awake

(LOC) Level of Consciousness

Oriented x 4:

Eyes

Unaided sight

Pupils

Equal

Lethargic Glasses

Round

Unaided hearing

Extremities

Hand grips

Pain

Contact lens

Reactive to light

Comatose

Confused

Decerebrate

Decorticate

Response to touch/voice Implants

Prosthesis

Accommodates

Snellen 20/

Sluggish

Brisk

Blind

Nonreactive to light

Consensual

Pupil size before light ______mm Pupil size after light ______mm

Ears

Cranial Nerves - intact

Stuper

Person Place Time Event

Hard of hearing

+1 +2 +3 +4 +5

I(smell)

II(vision)

VIII (hear/balance) Character

Deaf

Hearing aid

equal unequal

III+IV+VI(eye movement) IX (taste/swallow)

Onset

Location

Implant

Foot pushes

Severity

Drainage

equal unequal

V(sensation of face/oral)

X (chew/gag/speech)

Duration

Cerumen

+1 +2 +3 +4 +5

VII (facial movement/taste)

XI (shrug/turn head)

Pattern

XII(tongue movement)

Associated Factors

COLDSPA

CARDIOVASCULAR Skin / Mucous Membranes

Pink

Radial and Pedal Pulses

Radial: Palpable (L/R)

Pale

Cyanotic

Apical Radial Pulses

(2 people simultaneously)

Carotid Pulses

(DO NOT TAKE AT SAME TIME)

Capillary Refill

Normal (...