CLINICAL DECISION-MAKING THESIS
PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
| Student Name: | Week: | Dates of Care: |
| Patient Initials
|
Sex | Age | Room | Admitting Date | Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?
|
| Attending physician/Treatment team:
|
Consults: | ||||
| Present Diagnosis: (Why patient is currently in the hospital)
|
ER Management: (if applicable)
|
||||
| Allergies:
|
Code Status: | Isolation: (type and reason) | |||
| Admission Height:
|
Admission Weight: | Arm Band Location (colors & reasons)
|
|||
| Communication needs: (verbal, nonverbal, barriers, languages)
|
|||||
| Past Medical History: (pertinent & how managed)
|
|||||
| Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)
|
| Tests/Treatments/Interventions impacting clinical day’s care (include current orders)
|
| Assessments and interventions: (Include all pertinent data)
|
|
| Vital signs: (2 sets per day)
Time T P R B/P Time T P R B/P
|
GI:
Diet: Swallow precautions: Tube feedings: NG / G tube: Blood Glucose: (time & date) Last bowel movement: (time & date) Pertinent Labs/Test: Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)
|
| Respiratory:
02 modalities: 02 Saturation: Suction: Resp Rx’s: Trach: Chest Tubes: Pertinent Labs/Test: Assessments/Interventions: (Lung sounds, cough, sputum, SOB)
|
Neurosensory:
Neuro checks: Alert & Orientated: Follows commands: Speech Comprehensible: Pertinent Labs/Test: Assessments/Interventions: (LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness) |
| Cardiovascular:
Telemetry: Pacemaker/IAD: DVT Prevention: Daily Weights: Pertinent Labs/Test: Assessments/Interventions: (peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)
|
Musculoskeletal:
Activity: Traction: Casts/Slings: Pertinent Labs/Test: Assessments/Interventions: (strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps
|
| Renal:
Catheter (indwelling/external): CBI: Dialysis: A/V access: Pertinent Labs/Test: Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)
|
Skin:
Braden Score: Pertinent Labs/Test: Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)
|
| Pain:
Pain score: Assessments/Interventions: (scale used, location, duration, intensity, character, exacerbation, relief, interventions)
|
Vascular Access: (IV site)
Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)
|
| Gyn:
Gravida/Para: LMP: Last Pap: Breast exam: Pertinent Labs/Test Assessment/Interventions: (bleeding, discharge)
|
Post-operative /procedural:
Assessments/Interventions: (immediate post procedure care)
|
| Safety:
Call light: Bed Rails: Bed alarms: Fall risk: Assistive Devices: Sitter use: Restraints (type, duration & reason): Assessment/Interventions (modifications to room, environment, Patient)
|
Advance Directives/Ethical considerations:
DPOA: Hospice:
|
| Pertinent Data (Labs, X-rays, Etc.)
Results Normal Lab Values Significance to your patient WBC |
