NURS 3615
If you do not see your course in the Course Name dropdown, but the instructor has provided a
course enrollment key, click the Add a Course button, and enter the code provided by your
clinical instructor. If you do not have a course enrollment key, contact your instructor to be
added to the course. Enrollment Key:
You will then see the clinical worksheet/care plan assignment that is required for you to
complete.
1. Click-New Inpatient Chart
2. Create new patient
a. Initials of patient, sex, age, code status, and under comments add any additional
alerts.
3. Enter & Save...Under Provider
a. Chief complaint/History Present Illness (admission dx-other problems)
4. Enter & Save...Under Notes
a. New note- title other- In a narrative format type a complete HPI. HPI should be the
patient’s back story and include where patient admitted from, reason for admission,
pertinent history, and what has happened during hospitalization up to the day of your
care.
5. Enter & Save...Under Results
a. Labs- Include admission, most recent, and other pertinent values. Include serial labs
relevant to client’s condition (H/H for GI bleed, PTT for heparin drip, etc.) • All abnormal
labs must be explained with reasons and implications specific to the client (add separate
nursing note with this information)
b. Diagnostic tests- Relevant to patient’s diagnosis & explain with nursing
implications
6. Enter & Save....Orders
a. Allergies
b. Medication- Include top 3 priority medications (in comments section add reason
for taking and nursing implications)
7. Enter & Save....Under Flowsheets
a. Assessment (document BOTH negative and positive findings)
b. Vital signs (2-4 sets)
c. Daily Care
d. Intake & Output
e. Intervention (lines, drains)
f. Wounds, Incisions, Ostomies
8. Enter & Save....Under Screenings
a. Fall
b. Braden
9. Create new problem/need, Enter & Save.....Under Care Plan
a. Only assessment pertinent to nursing problem
b. Nursing Diagnosis/Problem
9.b.i. The first nursing diagnosis must be an actual problem (not at risk) and be
in 3- part NANDA terminology
9.b.ii. The second diagnosis must be a psychosocial diagnosis. It can be actual or
potential (at risk) diagnosis.
Spring 2022
NURS 3615
c. Outcome/Planning
9.c.i. One expected outcome/goal per each diagnosis (total of two)
d. Interventions
9.d.i. 3 interventions to address problem along with rationales per each nursing
diagnosis. (Total of 6).
e. Evaluation
9.e.i. Met, not met, partial met with explanation of how per each goal.
f. Additional information
9.f.i. References – should be in APA format
Spring 2022