Fill in the attached form about a patient
Student Name
Clinical Judgement Plan
West Coast University
Professor Name
Date
SK/DW 2/22 pg. 1
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
Patient Information
(1)
History of Present Illness (HPI)
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY
GOT TO THE HOSPITAL- UNTIL NOW WHEN YOU ARE PROVIDING CARE? (USE SEPARATE ATTACHED WORD DOC → WHEN
NEEDED) (SEE RUBRIC REQUIREMENTS)
Patient Initials:
Age & Gender: Age in years/not DOB
Height/Weight:
Code Status:
Medical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED MEDICAL PROBLEMS
For each disease identified, define, it, describe pathophysiology, and cite source
Living Will/ DPOA:
Chief Complaint
Ex: SUBJECTIVE (Abnormal – Bullet Points)
What is the cause of the patients problem
now describing i.e., Pt is having SOB 8/10
with exertion?
Surgical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED SURGICAL PROBLEMS
For each procedure identified, define & describe it; include year of procedure & cite source
Social History:
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
Admitting Diagnosis & Admission
Date
Cultural considerations, ethnicity, occupation, religion, family support, insurance.
(1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial
Considerations/Concerns: include the following Social Determinants of Health
(SDOH) (SEE RUBRIC REQUIREMENTS)
Erickson’s Developmental Stage Related to pt. & Cite References (1)
*List and Discuss specific stage (based on objective assessment)
(SEE RUBRIC REQUIREMENTS)
❋Economic Stability
❋ Education
❋Social and Community Context
❋ Health and Health Care
❋ Neighborhood and Built Environment
Final Version 3/10/22 DW/ss & MS Team
Clinical Judgement Plan
Medical Management and Collaborative Plan
(From MD, PT, OT notes…. etc.) *Consider past 24 – 48 hours
(SEE RUBRIC REQUIREMENTS)
Instructor:
DATE Care Provided and UNIT:
TIME OUT!!! Student instructions:
Include Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values
(With normal ranges), include dates and rationales supported with Evidence Based Citations
Include 2-3 nursing interventions for abnormal labs and for all diagnostic procedures
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE
EQUIPMENT
Lab Tests or
Diagnostic Scan
Normal
Ranges
Admission
Lab Values
Current Lab
Values
Explain Abnormal Labs R/T
Your Pt & NI
(USE SEPARATE ATTACHED
WORD DOC → WHEN
NEEDED)
MEDS
TREATMENT
TIME OUT!!! Student instructions:
(SEE RUBRIC REQUIREMENTS)
Patient Education (In Pt.) for Referrals/ Discharge Planning
REFERRALS NEEDED/CASE Management
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
TIME OUT!!! Student instructions:
Pathophysiology of Primary Medical Dx (reason for
hospitalization) Support with Evidence Based Citations
Pathophysiology of Primary Medical Dx (reason for
TIME OUT!!! Student
instructions:
INCLUDE:
Appropriate Diagnostic
Tests/ ProceduresDATEs and RESULTS
(Can add → See
attached Word Doc)
Ex: The primary pathophysiologic process in COPD is
persistent but variable inflammation of the airways
(SEE RUBRIC REQUIREMENTS)
hospitalization)
Final Version 3/10/22 DW/ss & MS Team
Clinical Judgement Plan
Instructor:
TIME OUT!!! Student instructions:
DATE Care Provided and UNIT:
Medication Name
Include BOTH Generic
AND Trade names for
RX; include OTC,
herbal (nonpharmacological items)
Dose
Medications & Allergies (2)
Route
Freq.
Indications
Mechanism of Action
NOTE:
PRN
‘alone’
≠ Freq
(PRN meds must
include MD
ordered Indication)
Final Version 3/10/22 DW/ss & MS Team
Side Effects/
Adverse Reactions
Nursing Considerations specific to this
patient with citations
What cues will you observe for?
What will you monitor (labs, vitals, etc?)
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
ASSESSMENT/History of Present Illness /REVIEW OF SYTEMS
TIME OUT!!! Student instructions:
Physical Assessment Findings including presenting signs and symptoms that you will complete for this patient supported with Evidence Based Citations
Vital Signs (4)
Neurological (5)
Cardiovascular (6)
Respiratory (7)
Musculoskeletal (8)
GI/Hydration/Nutrition (9)
GU (10)
Rest/ Exercise (11)
Integumentary (12)
Endocrine (13)
Psychosocial (14)
BP:
HR: (Rhythm)
RR:
Temp:
O2 (any supplemental)
Pain (0/10)
Ht (cm)
Wt. (Kg)
BMI:
Final Version 3/10/22 DW/ss & MS Team
MISC:
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
TIME OUT!!! Student instructions:
To be sure your clinical judgement statements written below are accurate. You need to review the defining characteristics and related factors associated with and see how your patient data match.
Do you have an accurate match or are additional data required, or does another cue from abnormal assessment findings need to be investigated?
Observation
Assessment
Recognize Cues
Obtain information from
different sources (e.g., the
environment, the pt., the
family, another nurse,
EHR) in different formats
(e.g., visual observation,
audio perception, lab
results, text description,
etc.).
Interpreting
Responding
Analysis
Analyze Cues
Interprets cues from their
existing knowledge base and
nursing perspective, evaluate
cues in terms of relevancy,
importance, and
interrelationship among other
cues, organize cues in the
mental representation of the
scenario (e.g., organize cues
in clusters), and then
develops a group of probable
client needs/concerns and
problems
Prioritize Hypotheses
Evaluates the probable client
needs/concerns and problems
generated previously in
various dimensions and
organize them into an ordered
list where the priority
hypotheses are on the top.
(ABCs, Maslow, safety, acute
v chronic, unstable v stable,
urgent v non-urgent)
Planning
Implement
Generate Solutions
Develops a list of actions to
address the hypotheses.
Give rationales for each
solution.
Take Action
Sorts the actions (based on
their evaluation in various
dimensions) and carries
out the action(s) to address
the hypothesis/hypotheses
with highest priority first.
Clinical Judgement (The expected/anticipated outcomes or SMART GOALS)
These should be written in a SMART format for patient goals.
For examples:
The patient will have decreased pain by verbalizing pain score 3/10 or below by the end of the shift.
The patient will maintain clear airway by effectively coughing by the end of the shift.
Reflecting
Evaluate
Evaluation
Compare and contrast what happened with your plan of care against what was expected/anticipated (disease progression, unique client
response) and decide whether additional clinical decisions are needed.
Final Version 3/10/22 DW/ss & MS Team
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
References
Use APA format and hanging indents for all references.
If you have any questions, please consult the APA 7th Edition.
Final Version 3/10/22 DW/ss & MS Team
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Title Page
Citation
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