We go the hospital the night before, wearing nice clothes (no jeans) and a labcoat with our id. We have to find out about the pt's diagnosis, diet, activity level, I&O, IV's - drug and rate, drains, PCA, medications, lab values, O2, dressing, surgical procedures, etc. Then at home we have to write up a page on the pathophysiology of their diagnosis, research all meds and create a careplan with a nursing diagnosis, 5 interventions and outcome statements. During the day of clinical, we have to complete a physical evaluation of all body systems and write nurses notes. We also chart diet, am care, I&O and activity into the hospital computer. The rest of the paperwork goes to our instructor.
It's a lot of paperwork, especially with multiple patients.