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Relearning: Clinical Judgment Plan of Care Template

Relearning Clinical Judgment Plan of Care Template-July24 © 2024 Chamberlain University. All Rights Reserved. 1

Student Name:

Client Initials:

Age/DOB:

Allergies:

BSA/BMI: Code Status:

Date of Admission:

Date of Care:

Admitting Diagnosis:

Comorbidities:

Planned Treatments/Procedures:

Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider orders

Cultural/Spiritual:

Neurological/Cognition/Coping/Adaptation/Function:

Nutrition/Elimination:

Fluid/Electrolytes/Acid-Base:

Gas Exchange/Perfusion:

Glucose Regulation:

Health Promotion/Development:

Infection/Immunity/Inflammation:

Mobility:

Pain/Comfort/Tissue Integrity:

Safety:

Other:

START of Shift (CJSim™) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to phase 1/Question 1 section)

Recognize & Analyze Cues Prioritize Hypotheses Generate Solutions & Take Actions Evaluate Outcomes

Priority Assessments/Cues Priority Hypotheses for Nursing Care Priority Interventions/Actions Priority Teaching/Discharge Needs

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2.

3.

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2.

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1.

2.

3.

1.

2.

3.

Priority Laboratory Tests/

Diagnostic Cues Priority Actual & Potential

Complications/Cues Priority Medications Priority Collaborative Actions

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2.

3.

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2.

3.

Relearning: Clinical Judgment Plan of Care Template

Relearning Clinical Judgment Plan of Care Template-July24 © 2024 Chamberlain University. All Rights Reserved. 2

Vital Signs & Pertinent Lab Trends

START of the Shift (CJSim™) Analysis (phase 1/Question 1 section) END of the Shift (CJSim™) Analysis (phase 3/Question 3 section)

(CJSim™) MID-SHIFT Purposeful Clinical Judgment (Complete after reviewing EHR/Question 2 section)

Answer these questions about today's client:

1. Recognize Cues — Explain any assessment changes since the start of shift.

2. Analyze Cues — How are the changes important or significant?

3. Prioritize Hypothesis — What could be causing the changes?

4. Generate Solutions — What can/should you do about these changes?

5. Take Action — What did I do about it? What would I do about it?

6. Evaluate Outcomes — Did my actions make a difference? Why are why not? What should have been done differently?

END of Shift (CJSim™) Priorities — How Has Your Client Changed? (phase 3/Question 3 section)

Recognize & Analyze Cues Prioritize Hypotheses Generate Solutions & Take Actions Evaluate Outcomes

Priority Assessments/Cues Priority Hypotheses for Nursing Care Priority Interventions/Actions Priority Teaching/Discharge Needs

1.

2.

3.

1.

2.

3.

1.

2.

3.

1.

2.

3.

Priority Laboratory Tests/

Diagnostic Cues Priority Actual & Potential

Complications/Cues Priority Medications Priority Collaborative Actions

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2.

3.

1.

2.

3.

1.

2.

3.

1.

2.

3.

Clinical Debriefing (Complete these questions after completely caring for the client and answering the questions for the client)

Answer these questions about today's client:

1. Compare this client with one that you've cared for previously in clinical, simulation, or a class case study. What things were the same and what was different related to their condition, assessment findings, provider prescriptions, medications, etc .?

2. Compare this client with the "textbook", what was the same and what was different?

Relearning: Clinical Judgment Plan of Care Template

Relearning Clinical Judgment Plan of Care Template-July24 © 2024 Chamberlain University. All Rights Reserved. 3

CONSIDER QUESTIONS Document the Answers to Your Questions Here

Consider Questions from CJSim™ Question #1 Consider Questions from CJSim™ Question #2 Consider Questions from CJSim™ Question #3

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Reflection Exercise (After providing care during the CJSim™ and completing the plan of care template for your assigned client, answer the following reflection

questions focusing on the care you provided for this CJSim™ client.)

CJSim™ Reflection Questions: 1. What additional information would you need to provide more comprehensive care for the client?

2. What could you have done better or differently to improve the outcome? Why?

3. Describe what was most challenging for you when caring for the clients in the CJSim™?

4. Identify the additional equipment, resources, or assistance needed to improve the care you provided.

5. Share the key areas of care that were new to you that you had not experienced before.

6. How will your above reflections impact your future practice and improve your clinical judgment?

NurseTim, Inc. (2021). NurseThink® clinical judgment plan for care template for CJSim RN .

CJSIMBenchmarkfundamental.pdf

Student Overview CLARIS NJIKE ID: D41284211

CourseFundamentals: Patient Care- Belcher

Instructor Elissa Belcher

AssessmentW7 NR226 CJE Fundamentals Benchmark 2551

Assessment Date 10/13/2025

MY SCORE

67.23%

CLASS AVERAGE

68.69% NATIONAL AVERAGE

65.37%

StdDev 0.0857

Mean 34.3444

Median 34.4583 Rank 5 / 6

Class Percentile 0.25

National Percentile0.5635

Category Performance

Student Score National Average Average Score Range Needs Improvement

Needs Review Doing Well

NurseThink Testing

119 items

Category Name Student Score National Average Class Average Points Status

CJE Exam Version

67.23% 65.37% 68.69% 33.616667

CJE Benchmark

67.23% 65.37% 68.69% 33.616667

Clinical Judgment Measurement Model

67.23% 65.37% 68.69% 33.616667

1-Recognize Cues 78.57% 69.71% 75.79% 5.5

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10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report

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Category Name Student Score National Average Class Average Points Status

2-Analyze Cues

58.5% 56.4% 59.42% 5.85

3-Prioritize Hypotheses

73.81% 70.69% 77.38% 5.166667

4-Generate Solutions

71.43% 64.46% 64.76% 5

5-Take Actions

77.78% 70.53% 71.3% 7

6-Evaluate Outcomes

51% 63.55% 67.31% 5.1

Concept

67.23% 65.37% 68.69% 33.616667

Accountability Concept

53.33% 45.55% 71.11% 1.6

Advocacy Concept

100% 40.16% 16.67% 1

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Category Name Student Score National Average Class Average Points Status

Clotting Concept

100% 83.61% 83.33% 1

Comfort Concept

68.75% 73.55% 71.18% 2.75

Communication Concept

56.25% 63.58% 75% 2.25

Culture Concept

50% 68.34% 75% 1

Ethics Concept

100% 91.75% 86.11% 3

Fluid & Electrolyte Balance Concept

86.67% 78.21% 85.56% 2.6

Functional Ability Concept

45.83% 61.51% 60.42% 0.916667

Health Promotion Concept

50% 70.08% 58.33% 0.5

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Category Name Student Score National Average Class Average Points Status

Infection Concept

100% 57.4% 100% 2

Intracranial Regulation Concept

100% 32.44% 33.33% 1

Legal Issues Concept

0% 75.94% 83.33% 0

Mobility Concept

50% 48.7% 50% 1

Nutrition Concept

66.67% 52.58% 61.11% 2

Oxygenation & Gas Exchange Concept

50% 69.88% 50% 1

Perfusion Concept

50% 48.23% 58.33% 1

Professionalism Concept

100% 53.51% 50% 1

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Category Name Student Score National Average Class Average Points Status

Safety Concept

58.33% 74.62% 78.7% 3.5

Sensory Perception Concept

0% 7.18% 0% 0

Sexuality Concept

100% 92.74% 100% 1

Stress & Coping Concept

100% 82.01% 93.33% 2

Tissue Integrity Concept

75% 70% 33.33% 1.5

Exemplar-Disease

67.23% 65.37% 68.69% 33.616667

Advocacy

100% 40.16% 16.67% 1

Antibiotic Resistant Infection

100% 56.49% 100% 1

Asthma 0% 68.6% 16.67% 0

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Category Name Student Score National Average Class Average Points Status

Care Coordination

60% 70.53% 73.33% 0.6

Chronic Kidney Disease

100% 63.66% 83.33% 1

Deep Vein Thrombosis (DVT)

100% 83.61% 83.33% 1

Devices & Restraints

0% 75.94% 83.33% 0

Diabetes

60% 67.99% 80% 0.6

Documentation

0% 40.66% 66.67% 0

End-of-Life Care

100% 86.48% 66.67% 1

Enteral and Parenteral Nutrition

100% 64.02% 100% 1

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Category Name Student Score National Average Class Average Points Status

Ethical Principles

100% 53.51% 50% 1

Falls

50% 68.34% 83.33% 1

Fibromyalgia

30.56% 64.17% 58.8% 0.916667

Fluid Overload

100% 93.01% 100% 1

Grief

100% 76.64% 100% 1

Handoff Communication

0% 51.23% 66.67% 0

Heart Failure

100% 71.09% 83.33% 1

Hypertension (HTN)

0% 32.79% 33.33% 0

Isolation Precautions

100% 75.56% 95.83% 2

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Category Name Student Score National Average Class Average Points Status

Malnutrition

100% 65.71% 83.33% 1

Medication Administration

71.43% 68.02% 73.41% 5

Mobility Techniques & Devices

50% 48.7% 50% 1

Pain: Acute & Chronic

91.67% 74.9% 76.39% 2.75

Patient Education

12.5% 69.99% 58.33% 0.25

Patient Rights & Confidentiality

100% 95.96% 100% 1

Postoperative Care

0% 28.02% 0% 0

Preoperative Care 100% 55.93% 100% 1

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Category Name Student Score National Average Class Average Points Status

Pressure Injury

100% 72.57% 33.33% 1

Sexually Transmitted Infections (STIs)

100% 92.74% 100% 1

Spinal Cord Injuries

100% 71.16% 83.33% 1

Therapeutic Communication

100% 82.1% 85% 2

Traumatic Brain Injury

100% 32.44% 33.33% 1

Visual Impairment

0% 7.18% 0% 0

Wound Care & Wound Healing

50% 67.43% 33.33% 0.5

Item Type

67.23% 65.37% 68.69% 33.616667

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Category Name Student Score National Average Class Average Points Status

Calculation

100% 90.07% 83.33% 1

Cloze

25% 68.46% 44.44% 0.5

Highlight

50% 30.4% 50% 1

HotSpot

0% 28.02% 0% 0

Matrix

86.67% 76.12% 77.78% 2.6

Multiple Choice

78.57% 66.93% 75% 22

Multiple Response

54.31% 67.22% 64.91% 6.516667

Ordering

0% 43.35% 50% 0

NCLEX® Client Needs

67.23% 65.37% 68.69% 33.616667

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Category Name Student Score National Average Class Average Points Status

Basic Care and Comfort

76.85% 65.26% 68.98% 6.916667

Health Promotion and Maintenance

76.67% 70.12% 75.42% 4.6

Management of Care

65.71% 64.89% 62.22% 4.6

Pharmacological and Parenteral Therapies

57.14% 68.25% 63.89% 4

Physiological Adaptation

70% 65.61% 66.67% 3.5

Psychosocial Integrity

66.67% 64.12% 70% 4

Reduction of Risk Potential

60% 56.15% 56.67% 3

Safety and Infection Control

60% 66.96% 88.33% 3

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Category Name Student Score National Average Class Average Points Status

QSEN Competencies

67.23% 65.37% 68.69% 33.616667

Evidence-based Practice

62.5% 70.64% 67.71% 5

Informatics

50% 47.09% 58.33% 1

Patient-Centered Care

78.65% 69.08% 71.38% 16.516667

Safety

56.67% 60.2% 66.48% 8.5

Teamwork and Collaboration

65% 63.83% 70% 2.6

RN Nursing Process

67.23% 65.37% 68.69% 33.616667

1-Assessment 78.57% 69.71% 75.79% 5.5

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Category Name Student Score National Average Class Average Points Status

2-Analysis

64.8% 62.28% 66.81% 11.016667

3-Planning

71.43% 64.46% 64.76% 5

4-Implementation

77.78% 70.53% 71.3% 7

5-Evaluation

51% 63.55% 67.31% 5.1

Specialty Focus

67.23% 65.37% 68.69% 33.616667

Fundamentals

67.23% 65.37% 68.69% 33.616667

System

67.23% 65.37% 68.69% 33.616667

Cardiovascular System

33.33% 62.62% 61.11% 1

Community System 100% 76.64% 100% 1

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Category Name Student Score National Average Class Average Points Status

Fluid Electrolyte Acid-Base System

100% 71.09% 83.33% 1

Gastrointestinal System

75% 58.06% 68.75% 3

Immune System

100% 57.4% 100% 2

Integumentary System

75% 70% 33.33% 1.5

Leadership System

66.67% 66.51% 68.06% 4

Multisystem

51.94% 66.37% 70.69% 3.116667

Musculoskeletal System

50% 48.7% 50% 1

Neurological System

83.33% 43.51% 52.78% 2.5

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Category Name Student Score National Average Class Average Points Status

Pain System

68.75% 73.55% 71.18% 2.75

Psychosocial System

81.25% 80.26% 71.67% 3.25

Renal System

100% 78.34% 91.67% 2

Reproductive System

100% 92.74% 100% 1

Respiratory System

50% 69.88% 50% 1

Safety System

58.33% 68.16% 80.09% 3.5

Sensory System

0% 7.18% 0% 0

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