NURS 206 PDBSN 2023- Clinical Assignment Data Collection Tool
Data Collection
Patient SITUATION (tell your patients story)
Client’s Initials: _______ Age:_______
Room______
Date admitted:
Admitting diagnoses:
Confirmed diagnoses:
Allergies (reaction):
Code Status:
Interprofessional Referrals
Vital Signs (include interpretation)
Physiotherapy:
Occupational Therapy:
Date_____
BP____P_____R_____T_____Sa02_____Pain score_____
Dietician:
Respiratory therapy:
Infection control:
Date ____
BP____P____R_____T_____Sa02_____Pain____
Date_____
BP____P_____R_____T_____Sa02_____Pain____
BACKGROUND
Assessments
Medical:
Personal Hygiene:
Surgical:
Mobility orders/TLR
Psychosocial:
Activity orders
Mobility Devices used: (wheelchair, walker, lift)
Safety Needs
Adapted by Regine Gerow-Scissons 2023 from Tania Bergen’s N221 Clinical Data Collection
Elimination:
Treatments:
Bowel Pattern_____ Last BM
Ostomy______ Ostomy care orders
N/G drainage ________ Orders________
Oxygenation:
02 orders______
Device_______
Tracheostomy care______
Urinary Catheter:
Wound care:
Type of Dressing(s):
Site(s):
Type & Amount of Drainage:
Dressing change orders:
Drain(s) & output:
Physical Assessment Baseline
Other:
Additional Information
CNS
CVS
Education Needs
RESP
INTEG
Psychosocial & Cultural/Family
GI
GU
Discharge Planning/Transfer
MSK
EENT
Adapted by Regine Gerow-Scissons 2023 from Tania Bergen’s N221 Clinical Data Collection
NURS 206
CLINICAL Assignment Utilizing the Clinical Judgment Model
Student name_________________________________________ Date __________________
Patient initials: _____ Room number________
Data/ Patient Cues Nursing
Patient Centered Goal
Nursing interventions
(ASSESSMENT)
Priorities
(SMART:PLANNING/OUTCOMES) (IMPLEMENTATION of your SKILLS)
What assessments, education, treatments are required?
SUBJECTIVE and
(DIAGNOSIS)
OBJECTIVE
Adapted by Regine Gerow-Scissons 2023 from Tania Bergen’s N221 Clinical Assignment
Outcome of
Plan
(EVALUATION of
the GOAL)
NURS 206 STUDENT NAME__________________DATE__________Room___________PT initials________
Nursing Priority (S): __________________________________________________________________
Plan for the day. After you have completed your clinical prep, use this chart to make your outline for the day.
This is your “to-do” list from your Clinical Assignment and Data collection learning
Time
Nursing Intervention
Comments
0700
0730
8000
0830
0900
0930
1000
1030
1100
1130
1200
1230
1300
1330
1400
1430
Make sure you have included important things like am care, oral care, vital signs (if appropriate), documentation (to
instructor to review and then in chart), breaks,
Adapted by Regine Gerow-Scissons from Tania Bergen’s Hourly Plan N221