ISBAR Post Partum Newborn and BSN Level 3 Direct patient Care Documentation

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Clinical Learning – Direct Patient Care Documentation Level 3 Clinical Courses Page 1 of 13

Student Name: D#: Date:

Course: Session: Year:

DIRECTIONS

This Direct Patient Care Documentation must be completed for one patient whom you are providing direct care in a clinical learning setting. All information within this packet must be handwritten, (with the exception of the reflection journal) reviewed with your faculty on your assigned clinical day and submitted within 24 hours (or as directed by course coordinator). If additional space is needed, please use the back of each page. If any area within this packet was not performed, line out and place “N/A” in that section.

• Grading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the clinical learning evaluation. Satisfactory rating meets the following:

– Clinical Learning Competency: Completes all clinical learning experiences and requirements successfully (PO 5).

• Performance Descriptor: Completes all assignments related to the clinical learning experience within established guidelines.

• I-SBAR: Utilized for receiving report. Areas that indicate clinical significance are to be completed after patient report has been received. Students should deliver a hand-off report at the end of their shift to the bedside nurse.

• Assessment Findings, Labs and Healthcare Provider Orders: Document your initial and ongoing assessment findings, lab results with why they were drawn specifically for your patient and healthcare provider orders with why they were specifically ordered for your patient.

• ATI® Active Learning Templates Required:

– Diagnostic Procedure: Select one diagnostic procedure from the healthcare orders table and complete one Active Learning Template: Diagnostic Procedure. The selected diagnostic procedure should be one in which you have not previously completed a template for this session.

– Therapeutic Procedure: Select one therapeutic procedure from the healthcare orders table and complete one Active Learning Template: Therapeutic Procedure. The selected therapeutic procedure should be one in which you have not previously completed a template for this session.

– Nursing Skill: Select one nursing skill from the healthcare orders table and complete one Active Learning Template: Nursing Skill. The selected nursing skill should be one in which you have not previously completed a template for this session.

– Medications: Complete one Active Learning Template: Medication for each medication classification in which you have not previously completed a template.

• Reflection Journal – Complete a reflection journal and submit to your faculty (or as directed) within 24 hours of completing your clinical learning experience. Reflective journaling provides a format to share your knowledge, skills, experiences and personal reflection related to concepts and strategies learned throughout your program. What could you or did you delegate and to whom? Include ways you plan to care for yourself throughout your program. The reflection journal is required to be a typed Word document, Times New Roman 12-point font and minimum of one page and no more than three pages. At least one time during the session, faculty will select one of the following questions for you to reflect on. 1. Describe how racial/health disparities, health equality/inequality, and social justice/injustice could apply to the clinical

site/agency’s community. Consider the population and determine why this may be occurring. 2. Transportation and housing are drivers of health and equity. Describe the steps you would take as a nurse

to evaluate transportation and housing for your identified community population and what actions you could perform to identify resources.

3. How can nurses be change agents and advocate for their community? Provide at least two specific examples.

Clinical Learning – Direct Patient Care Documentation Level 3 Clinical Courses

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

Clinical Learning – Direct Patient Care Documentation Level 3 Clinical Courses Page 2 of 13

I-SBAR

I – Introduce Yourself

Your Name:

D#:

Your Title:

Reason for being there:

S – Situation

Patient:

Age:

Gender/Identity:

Height/Weight:

Allergies:

Code Status:

Advance Directive (durable power of attorney, living will, other) and Clinical Significance:

Privacy Code:

Date of Care/Time:

Attending Physician:

Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance:

Pathophysiology of Primary Medical Diagnosis:

B – Background

Include clinical significance with each:

Past Medical History: Past Surgical History:

Immunizations Received:

Social History/Socioeconomic Factors:

A – Assessment

Vital Signs:

B/P HR RR TEMP SP02 PAIN

Falls risk: Accu-check:

IV Site: IV Fluids: Lab/Test Results:

I and O

Isolation Isolation Precautions: Y N Contact Air Droplet

RESPIRATORY

CARDIOVASCULAR

NEUROLOGICAL

GI/GU

INTEGUMENTARY

PSYCHOLOGICAL FAMILY – SUPPORT

SAFETY Teaching needed:

Quality in Safety Education Nurses (QSEN) Risk(s) Identified:

R – REQUEST/ RECOMMENDATION

Hand off report to: From:

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Initial Assessment Findings & Time Vital signs: T: P: Resp: Sp02: BP: Height: Weight: Apical HR: Intake: Output: Pain scale used with rationale: O (Onset): Did your pain start suddenly or gradually get worse?

P (Palliative, Provocative) What makes the pain better/worse?

Q (Quality) How is the pain described?

R (Radiation) Does the pain travel or spread anywhere else? If so, where?

S (Severity) What is the intensity of the pain?

T (Temporal) Is the pain constant or does it come and go?

Head and neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea):

Respiratory (lung sounds, breathing effort, accessory muscles):

Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm):

Abdomen (inspection, bowel sounds, palpation, contour):

Bowel incontinence:

Bowel plan: Last BM:

Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils):

Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities):

Genitourinary (burning with urination, frequency, color of urine):

Urinary incontinence: Toileting plan:

Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.):

Abuse screen (physical, elderly, child, sexual, etc.):

IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type of IV fluid, assessment of IV site, last dressing change):

Psychological/Psychosocial/Family Support/Religious/ Cultural Dynamics:

Growth and Development: (Developmental stage according to Erikson and your assessment findings):

Ongoing Assessment Findings & Time Vital signs: T: P: Resp: Sp02: BP: Height: Weight: Apical HR: Intake: Output: Pain scale used with rationale: O (Onset): Did your pain start suddenly or gradually get worse?

P (Palliative, Provocative) What makes the pain better/worse?

Q (Quality) How is the pain described?

R (Radiation) Does the pain travel or spread anywhere else? If so, where?

S (Severity) What is the intensity of the pain?

T (Temporal) Is the pain constant or does it come and go?

Head and neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea):

Respiratory (lung sounds, breathing effort, accessory muscles):

Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm):

Abdomen (inspection, bowel sounds, palpation, contour):

Bowel incontinence:

Bowel plan: Last BM:

Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils):

Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities):

Genitourinary (burning with urination, frequency, color of urine):

Urinary incontinence: Toileting plan:

Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.):

Abuse screen (physical, elderly, child, sexual, etc.):

IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type of IV fluid, assessment of IV site, last dressing change):

Psychological/Psychosocial/Family Support/ Religious/ Cultural Dynamics:

Growth and Development: (Developmental stage according to Erikson and your assessment findings):

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

Clinical Learning – Direct Patient Care Documentation Level 3 Clinical Courses Page 4 of 13

NURSING NOTES

Date/Time Nursing Note

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Clinical Learning – Direct Patient Care Documentation Level 3 Clinical Courses Page 5 of 13

What assessment findings/cues are associated with your patient’s rhythm?

Identify the priority treatment based on your assessment findings (cues) and how you would evaluate for effectiveness.

LABS & DIAGNOSTICS

Test Result/ Date Norm Reason out of norm/reason for

drawing if normal or N/A if not drawn

WBC

RBC

Hgb

Hct

Plt

Chol

Trig

LDH

APTT

AST

ALT

Tdl*

Test Result/ Date Norm Reason out of norm/reason for

drawing if normal or N/A if not drawn

Glu

BUN

Creat

CO2

Phos

Mag

T. Pro

Alb

Tdl*

What patient findings would you anticipate with these laboratory findings?

* Therapeutic drug level

Telemetry Rhythm Strip

If applicable: Attach your patient’s rhythm strip below and determine the following information:

PRI: QRS: QT: Rate: Rhythm:

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

Clinical Learning – Direct Patient Care Documentation Level 3 Clinical Courses Page 6 of 13

HEALTHCARE PROVIDER PRESCRIPTIONS (ORDERS)

Items Order/ Frequency

Prioritization (Prioritize the healthcare provider prescriptions (orders) based on your assessment cues)

Reason (explain specifically why ordered for this patient and teaching required)

Diet

I/O

Activity

Accu-check

Foley

NG tube

PEG tube

PEJ tube

Chest tube

Trach

Suctioning

Drains

Ostomy

Dressing change and/or wound care

Treatments

Restraints

Safety devices

Special equipment

Other

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

Clinical Learning – Direct Patient Care Documentation Level 3 Clinical Courses Page 7 of 13

THE CLINICAL JUDGMENT MEASUREMENT MODEL The Clinical Judgment Measurement Model (CJMM) identifies six cognitive skills needed to make appropriate clinical judgments. Complete the following section using the CJMM and reflecting on all the data/cues (Assessment, Labs/Diagnostics, Prescriptions/Orders and Patient Information) from your assigned patient.

Recognize Cues – Identify relevant and important information from different sources (e.g., medical history, vital signs).

List the data/cues that are relevant and are interpreted as clinically significant.

Significant Data/Cue 1

Significant Data/Cue 2

Significant Data/Cue 3

Significant Data/Cue 4

Significant Data/Cue 5

Analyze Cues – Organizing and linking the recognized cues to the patient’s clinical presentation.

Interpret the relevant clinical data/cues. Identify the top three most likely problems. Is additional data needed to confirm the clinical significance of the cues at this point? Be specific; what additional data is needed to confirm?

Potential Problem 1 Potential Problem 2 Potential Problem 3

Additional Data Additional Data Additional Data

Prioritize Hypothesis – Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk, difficulty, time, etc.).

Of the potential problems you identified, which problem(s) is most likely present? Which problem is the most concerning and why?

RECOGNIZE CUES

ANALYZE CUES

PRIORITIZE HYPOTHESIS

GENERATE SOLUTIONS

TAKE ACTION

EVALUATE OUTCOMES

ASSESSMENT ANALYSIS PLANNING IMPLEMENTATION EVALUATION

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Generate Solutions – Identifying expected outcomes and using hypotheses to define a set of interventions for the expected outcomes.

Based on the most urgent problem, what are the priority actions/interventions? For each priority action, what are the desired outcomes?

Priority Action/Intervention 1 Priority Action/Intervention 2 Priority Action/Intervention 3

Expected Outcomes Expected Outcomes Expected Outcomes

Are there any interventions or actions that should be avoided? Include rationale.

Take Action – Implementing the solution(s) that addresses the highest priorities.

How should the interventions or actions above be accomplished? (Performed, administered, requested, communicated, taught, documented, etc..).

List environmental and/or individual factors impacting the ability of the nurse to generate solutions and take action.

Environmental Factor 1

Individual Factor 1

Environmental Factor 2

Individual Factor 2

Environmental Factor 3

Individual Factor 3

Evaluate Outcomes – Comparing observed outcomes against expected outcomes.

Compare observed outcomes to expected outcomes – has the patient’s status improved, declined or remain unchanged?

Does the observed outcome match expected outcome? If not, what are the additional actions/interventions that should be considered?

Observed Outcomes Observed Outcomes Observed Outcomes

Matches Expected Outcome? Matches Expected Outcome? Matches Expected Outcome?

If the patient status has not improved, what other issues may be present?

List environmental and/or individual factors impacting the achievement of outcomes.

Environmental Factor 1

Individual Factor 1

Environmental Factor 2

Individual Factor 2

Environmental Factor 3

Individual Factor 3

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Priority (Top 3) Discharge Instructions and Evaluation of Effectiveness of Teaching (Include resources to mitigate SDOH and healthcare disparities.

Include teach/back and/or verbalized understanding)

CONCEPT MAP

Student Name: Date:

Priority (Top 3) Interventions, Rationales and Education to

Perform for Nursing Diagnosis

Potential and Actual Complications (Include dietary risk factors)

Priority (Top 3) Contributing Social Determinants of Health (SDOH)/

Healthcare Disparities Factors

Priority (Top 3) Information/Findings/ Signs and Symptoms (Cues)

Priority (Top 3) Lab Values/Diagnostic Results Related to Nursing Diagnosis

Identify how the Four Spheres of Care (AACN, 2019) were addressed

while caring for your patient. If a sphere is not applicable, provide rationale and/or exploration of how this could be incorporated into care.

1. Wellness, Disease Prevention (includes physical and mental

health needs). 2. Chronic Disease Management

(includes managing chronic disease and preventing further complications).

3. Regenerative /Restorative Care (includes complex acute, trauma

and critical care and acute exacerbations of chronic conditions). 4. Hospice/Palliative Care (includes end of life care and supportive care

for complex diseases and/or rehabilitative care).

Priority (Top 3) Patient Outcomes and Actions to evaluate the Outcomes

Priority (Top 3) Medication(s) and Patient Teaching r/t Diagnosis.

(Include medication side effects and nursing interventions for each)

Nursing Diagnosis

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Clinical Learning – Direct Patient Care Documentation Level 3 Clinical Courses Page 10 of 13

Active Learning Template – Diagnostic Procedure

Student Name:

Procedure Name: Review Module Chapter:

Description of Procedure:

Considerations

Indications Nursing Interventions (pre, intra, post)

Interpretation of Findings Client Education

Potential Complications Nursing Interventions

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

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Active Learning Template – Therapeutic Procedure

Student Name:

Procedure Name: Review Module Chapter:

Description of Procedure:

Considerations

Indications Nursing Interventions (pre, intra, post)

Outcomes/Evaluation Client Education

Potential Complications Nursing Interventions

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

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Active Learning Template – Nursing Skill

Student Name:

Skill Name: Review Module Chapter:

Description of Skill:

Considerations

Indications Nursing Interventions (pre, intra, post)

Outcomes/Evaluation Client Education

Potential Complications Nursing Interventions

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661

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Active Learning Template – Medication

Student Name: Medication/Time Due:

Review Module Chapter: Category Class:

Purpose of Medication

Expected Pharmacological Action Therapeutic Use

Complications Medication Administration

Contraindications/Precautions Nursing Interventions

Interactions Client Education

Evaluation of Medication Effectiveness Safety & Risk Considerations

I-SBAR
Initial Assessment Findings and Time:
Telemetry Rhythm Strip:
Healthcare Provider Orders
Concept Map
Active Learning Template:
Active Learning Template:
Active Learning Template:
Active Learning Template:

Student Name:
Course:
D Number:
Session: []
Year:
D Number 1:
Your Name:
D Number 2:
Your Title:
Reason for being there:
Patient:
Age:
Gender:
HeightWeight:
Allergies:
CodeStatus:
PrivacyCode:
DateofCare:
Safety-Teaching Needed:
Safety-QSEN:
DateofCare 10:
Recommendation:
Respiratory 3:
I and O:
Cardiovascular 3:
Neurological 3:
GIGU:
Integumentary 5:
Psychological Family Support:
IVsite:
IVfluids:
results:
AttendingPhysician:
Signficance:
Pathophysiology:
PastMedicalHistory:
PastSurgicalHistory:
SocialHistory:
Immu Receieved:
BP:
BP 2:
FallsRisk:
AccuCheck:
HR:
HR 2:
RR:
RR 2:
TEMP:
TEMP 2:
SPO:
SPO2:
PAIN:
PAIN 2:
ClinicalSignificance:
Isolation Precautions Yes: Off
Contact Air: Off
Contact Air 1: Off
Contact Droplet: Off
Isolation Precautions No: Off
Request-From 2:
Request-From:
Vital Signs-T 2:
Vital Signs-T 3:
Vital Signs-P:
Vital Signs-P 2:
Vital Signs-Resp:
Vital Signs-Resp 2:
Vital Signs-SpO2:
Vital Signs-SpO2 2:
Vital Signs-BP :
Vital Signs-BP 1:
Vital Signs-BP 3:
Vital Signs-BP 2:
Vital Signs-BP 4:
Vital Signs-BP 2:
Vital Signs-Height:
Vital Signs-Height 2:
Vital Signs-Weight:
Vital Signs-Weight 2:
Vital Signs-Apical HR:
Vital Signs-Apical HR 2:
Pain Scale Used with Rationale:
Pain Scale Used with Rationale 3:
AbInspection:
AbInspection 2:
Genitourinary:
Genitourinary 2:
Pelvic:
Pelvic 2:
Rectal:
Rectal 2:
Integumentary:
Integumentary 2:
Specialty assessment:
Specialty assessment 2:
Abuse screen:
Abuse screen 2:
IV access:
IV access 1:
IV access 4:
IV access 3:
IV access 5:
IV access 2:
Urinary incontinence:
Urinary incontinence 2:
Toilet Plan:
Toilet Plan 2:
Bowel incontinence:
Bowel incontinence 2:
Last Bowel Movement:
Last Bowel Movement 2:
Neurological:
Neurological 2:
Musculoskeletal:
Musculoskeletal 2:
Bowel Plan:
Bowel Plan 2:
Pain Scale-P:
Pain Scale-P 1:
Pain Scale-P 2:
Pain Scale-P 3:
Pain Scale-Q:
Pain Scale-Q 2:
Pain Scale-R:
Pain Scale-R 2:
Pain Scale-S:
Pain Scale-S 2:
Pain Scale-T:
Pain Scale-T 2:
HeadNeck:
Head Neck 2:
Respiratory:
Respiratory 2:
Cardio:
Cardio 2:
Text Field 1:
Text Field 31:
Text Field 16:
Text Field 32:
Text Field 4:
Text Field 33:
Text Field 17:
Text Field 34:
Text Field 61:
Text Field 7:
Text Field 35:
Text Field 18:
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Text Field 62:
Text Field 10:
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Text Field 15:
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PRI:
PRI 1:
PRI 2:
PRI 3:
PRI 4:
Telemetry Rhythm Strip text box:
QRS:
QT:
Rate:
Rhythm:
Result Date 12:
Result Date 30:
Result Date 9:
Result Date 27:
Result Date 6:
Result Date 24:
Result Date 3:
Result Date 21:
Result Date 11:
Result Date 29:
Result Date 8:
Result Date 26:
Result Date 5:
Result Date 23:
Result Date 2:
Result Date 20:
Result Date 13:
Result Date 14:
Result Date 16:
Result Date 15:
Result Date 17:
Test Opt 1:
Test Opt 3:
Test Opt 2:
Test Opt 4:
Result Date 31:
Result Date 10:
Result Date 28:
Result Date 7:
Result Date 25:
Result Date 4:
Result Date 22:
Result Date 1:
Result Date 19:
Norm 12:
Norm 30:
Norm 9:
Norm 27:
Norm 6:
Norm 24:
Norm 3:
Norm 21:
Norm 11:
Norm 29:
Norm 8:
Norm 26:
Norm 5:
Norm 23:
Norm 2:
Norm 20:
Norm 13:
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Norm 16:
Norm 15:
Norm 17:
Norm 31:
Norm 10:
Norm 28:
Norm 7:
Norm 25:
Norm 4:
Norm 22:
Norm 1:
Norm 19:
Reason 2:
Reason 20:
Reason:
Reason 19:
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Order Frequency 1:
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Item Opt 1:
Item Opt 2:
Item Opt 3:
Item Opt 4:
Reason 37:
Reason 60:
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Significant Data/Cue 2:
Potential Problem 2:
Additional Data 2:
Prioritize Hypothesis 2:
Additional Data 3:
Additional Data 4:
Potential Problem 3:
Potential Problem 4:
Significant Data/Cue 3:
Significant Data/Cue 4:
Significant Data/Cue 5:
Significant Data/Cue 6:
Priority Action/Intervention 5:
Expected Outcomes 4:
Expected Outcomes 5:
Expected Outcomes 6:
Are there any interventions or actions that should be avoided? 2:
Take Action 5:
Environmental Factor 8:
Observed Outcomes 4:
Matches Expected Outcome? 4:
what other issues may be present 4:
what other issues may be present 5:
what other issues may be present 6:
Matches Expected Outcome? 5:
Matches Expected Outcome? 6:
Observed Outcomes 5:
Observed Outcomes 6:
Environmental Factor 9:
Individual Factor 8:
Individual Factor 9:
Individual Factor 10:
Individual Factor 11:
Individual Factor 12:
Individual Factor 13:
Environmental Factor 10:
Environmental Factor 11:
Environmental Factor 12:
Environmental Factor 13:
Take Action 6:
Take Action 7:
Priority Action/Intervention 6:
Priority Action/Intervention 7:
Student Name 2:
Date 2:
Interventions for Nursing Diagnosis:
Signs and Symptoms:
Lab Values Related to Nursing Diagnosis:
Nursing Diagnosis:
Potential and Actual Complications:
Priority (Top 3) Patient Outcomes and Actions to evaluate the Outcomes:
Priority (Top 3) Discharge Instructions and Evaluation of Effectiveness of Teaching:
Medication Side Effects 2:
Priority Contributing Social Determinants of Health (SDOH)/Healthcare Disparities Factors:
Priority Medication(s) and Patient Teaching r/t Diagnosis:
Description of Procedure:
Procedure Name:
Review Module Chapter:
Indications:
Interpretation of Findings:
Potential Complications:
Nursing Interventions:
Client Education:
Nursing Interventions 1:
Student Name 4:
Description of Procedure 2:
Procedure Name 2:
Review Module Chapter 2:
Indications 2:
Outcomes Evaluation 2:
Potential Complications 2:
Nursing Interventions 2:
Client Education 2:
Nursing Interventions 3:
Student Name 3:
Description of Procedure 5:
Skill Name 5:
Review Module Chapter 5:
Indications 3:
Interpretation of Findings 3:
Potential Complications 3:
Nursing Interventions 4:
Client Education 3:
Nursing Interventions 5:
Student Name 6:
Review Module Chapter 6:
Medication 6:
Category Class 6:
Expected Pharmacological Action 4:
Complications 4:
Contraindications Precautions 4:
Interactions 4:
Therapeutic Use 4:
Medication Administration 4:
Nursing Interventions 6:
Client Education 4:
Safety & Risk Considerations:
Evaluation of Medication Effectiveness 4: