NSG 3027 Clinical Paperwork

What Is Due When• ACH Patient Care Areas

– Charting Packet– Medication Profile– Problem List– Care Plan (2 Satisfactory)– Pediatric Health Status

Assessment (1 Satisfactory)

• ACH Observation Areas– Clinical Log – Problem List

• Easter Seals– Clinical Log– Medication Profile– Problem List

• All Other Community Areas– Clinical Log– Medication Profile– Problem List– Nurse Preceptor Evaluation

Clinical Log• Before you arrive, you must develop at least

3 3 learning objectives which must be signed must be signed and dated and dated by your preceptor.preceptor.– Examples:

• Bad- “I want to observe the role of a school nurse”• Bad- “Learn to give meds”• Good- “I want to better understand to process

surrounding suspected child abuse”

Clinical Log

• Record in 30 minute increments• Use correct grammar and spelling• Must include an example of health teaching each dayeach day• Use telegraphic style.

Examples:Bad- 0800: I walked into the office to meet with

the nurse and I started thinking that this might turn out to be a busy day

Bad- 1200: For lunch I went to Wendy’s Bad- 1330: Kid came in with scratch. We put a Band-Aid

on it and sent him back to class.Good- 0800: “6 y/o WF with C/O ear ache. Temp 99.6,

fluid noted in both ears upon inspection. Child reports having taken Tylenol this A.M. Father called. Father will come pick up student”

Charting Packet

• Must maintain patient confidentiality• Perform a focused physical assessment each

day on your assigned patient• Must cover all areas

Problem List• Minimum of 55 problems per assigned

patient• Prioritize all nursing diagnoses daily• Provide a brief patient history including

all pertinent information to validate problem list

Care Plan• Must complete 2 2 satisfactory• Each care plan consists of 2 problems2 problems• Nursing diagnoses must be the top 2

problems from the problem list• Must include a minimum of 5 5 interventions• Must include patient/family teaching

Medication Profile• Must be completed and shown to your instructor before

you will be allowed to pass medications• Must be filled out on all scheduled and prn medications

received by the assigned patient• Dosage calculations must prove that the dose is within

the safe range and that the patient is receiving the correct amount

Health Status Assessment• Must complete 1 satisfactorily• Must address all areas on form• Must maintain patient confidentialitypatient confidentiality• Must use correct grammar, spelling, and medical

terminology

Growth and Development

• Must complete 11 satisfactory EriksonErikson• Must complete 11 satisfactory KohlbergKohlberg• Must complete 11 satisfactory PiagetPiaget• Refer to your guidelines

Questions?