Clinical log

INTERNATIONAL MEDICAL UNIVERSITY

BACHELOR OF NURSING SCIENCE (HONS)

NURS 1410 ADVANCING NURSES’ HEALTH ASSESSMENT SKILLS

CLINICAL LOG RECORD

Introduction

The log of clinical experience is for you to create and maintain a record of what you have done during the clinical placement. In this module the log of clinical experience will help you put to practice what you have learnt from health assessment and identify any gaps in experience or areas within this module which you need to improve on.

Clinical Objectives:

1. Collect subjective data by interviewing patient/client on the holistic aspects (physical, spiritual, cultural and psychosocial), reason for seeking healthcare, present health or history of present illness, past history, family history, review of systems, activities of living (ALs) using the Roper, Logan and Tierney’s model of nursing.

2. Collect objective data by completing physical assessment.

3. Identify normal and abnormal findings from inspection, palpation, percussion and auscultation during physical examination.

4. Use subjective and objective data to analyse findings and formulate nursing diagnoses upon completion of the assessments.

5. Demonstrate adherence to the responsibilities of professional practice within the ethical and legal framework of nursing and maintain confidentiality of information regarding patients.

6. Acknowledge the importance of working and collaborating as an effective team member with other health care professionals throughout the assessment process.

7. Reflect on your experience of practice when performing health assessment.

Instructions:

As partial fulfilment of the module you are required to complete a clinical log that will reflect a total of 6 credits. In order to meet the required credits and to achieve your clinical objectives, you need to spend at least 14 hours per week for a period of 6 weeks (this will translate to 84 hours, however you can spend more than 84 hours) in the clinical setting applying health assessment knowledge and skills to practice in the care of your patients / clients. During the time you clock in the clinical setting, you are expected to interview patients/clients and practise your physical examination techniques by carrying out examinations on sections of the body of your patients / clients.

For the FINAL clinical log, you are only required to narrate in simple and concise manner all the data collected from ONE comprehensive head-to-toe health assessment carried out on a client / patient into the health assessment form provided.

In your weekly clinical log, you are also required to reflect on your own performance so as to improve and refine your health assessment knowledge and skills.

Following the above, please take note that:

· you must use the clinical log template and health assessment form provided

· each log entry must address the specified clinical objective(s)

· you must support your assessment findings with specific evidence where applicable / possible

· you must correctly acknowledge and document sources in APA style where applicable

· your weekly log must have the supervisor’s signature and stamp before uploading it online

· you are required to submit your weekly clinical log with reflection of your experience in practice when performing health assessment online by each Sunday of the week latest @ 2355 hours

INTERNATIONAL MEDICAL UNIVERSITYBACHELOR OF NURSING SCIENCE (HONS)

NURS 1410 ADVANCING NURSES’ HEALTH ASSESSMENT SKILLS

CLINICAL LOG RECORD

STUDENT NAME: ______________________________________ STUDENT NO.: ______________________

UNIT / Department: _____________________________________

FACILITATOR: ________________________________________

Day, Date & time	Practicum Hours	Cumulative hours	Provide brief demographic information, diagnosis and status of client/patient	Clinical practice activities carried out and achieved objective (s) of the week.

INTERNATIONAL MEDICAL UNIVERSITY

BACHELOR OF NURSING SCIENCE (HONS)

NURS 1410 ADVANCING NURSES’ HEALTH ASSESSMENT SKILLS

HEALTH ASSESSMENT FORM

Patient name: _________________________ Diagnosis: __________________________________

Age: ____________ Sex: ________________ Date: _______________________

** Student is to write out a narrative assessment of patient on the columns provided.

A. Reason for seeking healthcare:

___________________________________________________________________________________

___________________________________________________________________________________

B. Social history and economic status:

C. Cultural and spiritual history:

D. Functional assessment: Activities of Living

E. History of present illness (e.g. OLDCARTS or PQRSTU )	F. Past medical and surgical history
G. Pertinent family history (genogram if possible)	H. Allergies, immunisation and medication
I. General survey	J. Vital signs and measurement (+nutritional status)

K. Pertinent laboratory or radiology investigations:

FOCUSED ASSESSMENT

L. Body Systems Review (Subjective data via history taking on affected and related body systems based on

the patient’s diagnosis and chief complaint)

M. Focused Physical Examination (Objective data)

**depending on the patient’s medical diagnosis, chief complaint and affected body systems. For example, if the

patient is admitted with chest pain, then perform focused physical examination on Cardiovascular system. If

the patient also complained of coughing, then must include the examination of Respiratory system as well.

N. Identified patient’s problems:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

O. Formulate THREE (3) nursing diagnoses using PES format:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Student name: ………………………………………… ID: ……………………………………………

Student’s signature: ………………………………………

Date : ……………………………………… Time: ……………………………………………

Reflective notes Week:	Clinical preceptor / supervisor evaluation on student’s professional and ethical responsibilities: Criteria Please circle the respective score: Non-compliance = 0 Partial compliance = 1 Compliance = 2 · maintain confidentiality of information regarding patients 0 1 2 · practice within the ethical and legal framework of nursing 0 1 2 · assume responsibility and accountability for own actions 0 1 2 · demonstrate the following for continuous learning and self-development.: · initiative · enthusiasm 0 0 1 1 2 2
· Describe briefly the assessment experience.
· Express personal thoughts and feelings about the experience (was it good or was it unpleasant)
· Reflection–in-action: Did you make any adjustment while performing the assessment on your client/patient while experiencing problem /situation related to your interviewing skill or examination technique? What did you do to resolve the problem / situations? OR What have you not done?	Clinical preceptor / supervisor overall comments on student’s performance:
· Reflection–on-action and clinical learning: a) Describe 2 ways your nursing health assessment skills expanded during this experience b) Name 2 things you might do differently if you encounter this kind of situation again c) What additional knowledge, information and skills do you need when encountering this kind of situation or similar situation in the future? d) Describe any changes in your values or feelings as a result of this experience.
· Share any meaningful interactions you have had with other health care team members throughout the experience.

Student’s signature : _____________________________________

Supervisor’s name, signature and stamp: _____________________________________

Date : _____________________________________