Help Preparing for Clinical Day!

Excellent question! i've been working on creating a list for you. first,

• Assume you may end up having to write a care plan on the patient. after your clinical is over and the patient has been discharged, the information is no longer going to be easily available to you, so it is up to you to get the important facts.
• Getting information about a patient is part of the assessment process (data collection). The more you know, the more you'll understand about what is going on with the patient and the better you are able to make decisions about their care.
• No one can ever know the entire patient's medical history, even if you think you do. Sometimes even the patient can't remember everything.

According to one author (pamela schuster, concept mapping: a critical-thinking approach to care planning), 99% of assessment data comes from documentation that is in the medical record and obtaining it can be time-consuming. The other 1% is obtained when you are face-to-face with the patient and perform your own interview and physical assessment. Now, I've known that for years, but this was the first author that I've found who actually wrote it down in a book. That said, here's where to look and what data you might need:

Face sheet (typically one of the first pages in the chart)...

• patient's age (you need to know the normal growth and developmental tasks for the patient's age and how illness may/may not have affected that)
• gender
• marital status
• occupation
• admission date
• reason for admission (may be called the admission diagnosis, may include any planned surgical procedures)
• past medical diagnoses

Doctor's order sheets/physician's orders

• any DNR (do not resuscitate) order
• diet
• activity allowed
• orders for lab and diagnostic procedures
• medication orders
• iv orders
• other treatments (i.e., oxygen, catheters, ng tubes, dressing changes)
• support services (i.e., physical therapy, occupational therapy, speech therapy, respiratory therapy, social worker)
• consultations by other physicians, usually specialists

Physician's Progress Potes

• the patient's progress and response to medical treatment
• changes in the patient's condition
• medical and surgical procedures that have been performed and findings
• results of tests and procedures

Doctor's History and Physical Exam

Physician consultations

• the patients h&p by the admitting physician that includes a review of systems and past medical, family and social history
• any consultation reports that may also have some review of systems and past medical history
• the consultation section may contain consults by other ancillary services that don't have their own section in the chart

Surgical consents

• the name of the exact procedure(s) the patient has had or is to undergo (a surgical consent must have the complete name of the surgical procedure written out with no abbreviations)

Perative report

Pathology report

• date and name of surgical procedures done by physicians
• medical diagnoses
• findings
• full description of the procedure and any materials/prostheses placed in the patient's body
• report on any tissue biopsied or removed during a surgical procedure

Laboratory and Diagnostic Procedures

• date and time of collection and analysis/examination of blood, urine, stool and other body substances
• blood bank records (if the patient has had blood/blood products transfusions)
• x-ray reports
• ekg tracings and reports
• eeg tracings and reports

Nursing Admission Assessment

• past medical diagnoses
• past illnesses, injuries and surgeries
• if the patient has an advanced directive (living will, healthcare power of attorney)
• height and weight
• allergies
• medications taken at home
• home caregiver
• a nursing review of systems
• a nursing assessment of the patient's ability to perform adls

Nurses notes/flow sheets/graphic sheet

• graphic information (vital signs)
• i&o information (may indicate ivs and catheters)
• bm monitoring
• activity performed

Medication cart

• medication sheet/record
  iv therapy record
  • allergies
  • drugs/dosages/routes/times
  • iv solutions to be infused and rates

  double check the generic and/or brand names of the drugs listed on the medication sheet/record by looking at the labels on the drugs in the patient's bin.

The nurses station

• kardex
  • allergies (food and drug)
  • age, gender, admission date
  • diet
  • activity allowed
  • iv orders
  • surgical procedures
  • dnr orders
  • diagnostic tests to be done
  • ordered treatments (i.e., oxygen, catheters, ng tubes, dressing changes)
  • support services (i.e., physical therapy, occupational therapy, speech therapy, respiratory therapy, social worker, discharge planning)
  • consultations by other physician specialists

  blank copies of forms you are going to have to document on the next day to become familiar with what information goes on them and where. these forms can include:

  • assessment forms
  • fall risk assessment form
  • standardized pre-written care plans/clinical pathways
  • printed copies of standing orders
  • educational materials that might apply to your patient

The nurses who work on the unit, preferably the one assigned to your patient.

• anything you can't find on your own

to help you organize your clinical day, print out a copy of the student clinical report sheet for one patient to help you (link is at the bottom of all my posts).

This was developed to help students organize their clinical day. The critical thinking flow sheet for nursing students was developed to help include all the elements needed in writing a care plan, but there are some items on it that may help you determine the assessment data you want to collect.

Once you get this information then start looking up information about the medical diagnoses, procedures, lab tests, drugs and their side effects.

P.S. I forgot to add that when you are looking at any of the physician history & physicals or consultation reports read through them and look for reference to any symptoms the patient might be having. These same symptoms can be helpful to you later in determining nursing diagnoses if you have to construct a care plan. Also, on some of these different chart documents you may find evidence that the patient has a tube, drain or other medical device in them that wasn't mentioned anywhere else in the record (some people are just real good at observation and documenting these things!)

You are very welcome. This is information that should be posted on the forum for all students to see. I've gotten the impression that many students are not clear on exactly where assessment data can come from. I'll start working on a form that students can just take with them to fill out to guide them in the collection of this information. Good luck in your clinicals!