Student Name: ______________________________________ Alvin Community College ADN Program Date: _______________________ DAILY CLINICAL DOCUMENTATION CLIENT INFORMATION Special Precautions: (fall, bleeding, etc…) Isolation Type: Patient Initials: _________ Room # __________ Admit Date: ________/________/________ Age: ________ Gender: ________ Ethnicity: __________________________ Date of Care: ________/________/________ Code Status: ________________________ Admitting Diagnosis: ____________________________________________________________________________________________________ Med / Surg History: _____________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Additional Information:__________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ CURRENT LABS / DIAGNOSTIC TESTING (indicate with ↑↓ if lab values are above/below normal range) BMP/CMP CBC Date/Time: URINALYSIS TOXICOLOGY Date/Time: WBC RBC Protein Bilirubin Mg Phos Ca++ PT PTT INR Other INTERPRETATION OF CURRENT LAB RESULTS / DIAGNOSTIC TESTING OTHER LABS / DIAGNOSTIC TESTS ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ PREVIOUS LABS / DIAGNOSTIC TESTING (include date, name of lab, result, and indicate with ↑↓ if lab values are above/below normal range) _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ VITAL SIGNS BLOOD GLUCOSE CHECKS Frequency: ___________________ 0800: BP ______/______ HR ______ RR ______ T __________ O 2 Sat ______ Pain ______ Glucose result: ________________ 1200: BP ______/______ HR ______ RR ______ T __________ O 2 Sat ______ Pain ______ Glucose result: ________________ 1600: BP ______/______ HR ______ RR ______ T __________ O 2 Sat ______ Pain ______ Glucose result: ________________ 1 Student Name: ______________________________________ Date: _______________________ NUTRITION indicate % of diet eaten DIET ORDERED: Breakfast: __________ Lunch: __________ Dinner: __________ INTAKE AND OUTPUT PREVIOUS 240 INTAKE: __________ mL TOTAL SHIFT INTAKE: __________ mL PREVIOUS 240 OUTPUT: __________ mL TOTAL SHIFT OUTPUT: __________ mL Fluid Restriction (if applicable): : __________ mL If NOT being done Explain_________________________________ EKG INTERPRETATION Include your interpretation of rhythm and measurements of P, PRI and QRS. Trim off patient identifier and electronic interpretation. Place current ECG strip here PRI ______ QRS ______ Atrial Rate _____ Ventricular Rate_____ Interpretation of rhythm_____________________________________ NURSING PROCESS PRIORITY nursing diagnosis / related to / AEB (as evidenced by): _______________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Short term goal for PRIORITY nursing diagnosis: ____________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ GOAL was: (circle one) MET PARTIALLY - MET NOT – MET How do you know? (include if you will continue with POC or make changes and give potential POC for the future) 2 Student Name: ______________________________________ TIME: Date: _______________________ NURSING ASSESSMENT (Subjective & Objective) Neuro / LOC HEENT Respiratory CV GI GU Integumentary Musculoskeletal / Extremities Psychosocial (list all lines and include IV fluids patient is receiving - identify if solution is isotonic, hypotonic or hypertonic) Lines Interprofessional Care (PT, OT, RT, etc…) 3 Student Name: ______________________________________ Date: _______________________ Discharge Considerations Identify (3) factors to consider about this specific patient’s requirements for discharge and describe how they will be addressed. TIME NARRATIVE NURSING NOTES (this should include ALL interventions / evaluations / re-assessment) 4 Student Name: ______________________________________ Date: _______________________ ALLERGIES: Medications: Trade / Generic Name, Dose, Route, Frequency Classification & Why is YOUR patient on this medication Side Effects (most common) & Nursing Implications References: 5
