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Discussion

Looking for samples of clinical forms

Im working on a form to keep all my multiple pateints data on throughout a clinical day- does anyone have anything they have made up or bought that they are willing to share?

I have 3 Columns per page on mine with the following data:

Admit Dx

Health HX

Treatments to date

VS inc. pain

Report from previous shift

Abn Labs

Diaganostic test

BG check/Units given

Allergies

Diet/Activity

IV meds

Teaching topic

Nursing Dx for day

Interventions/Goals

THings to do.

On the back of the sheet I have Medications 9 per column

I have searched the internet and can find no sample forms- I thought maybe other students might be able to help;)

Featured Replies

I usually get a piece of paper and divide it up into however many pts and however many hours I have. Under the pt's dx I list allergies and then I list meds under the hour that they are to be given and other interventions at the time they need to be given. All the other info you are trying to keep track of seems to be alot. All of that should be easy access in the pt chart so I wouldn't waste time trying to write it all down. I don't know what you are required to do either. ;)

  • Author

All of what I listed is part of our instructors care plan we have to complete on each pt. I get to clinicals 45 minutes early and barely have time to look at charts - most of the information we have to obtain from the patient (excpet meds, labs, diag test, etc.) We are not allowed to print anything from the pts chart (HIPPA)

Trust me, I think its alot as well, but its what the instructor wants - All that information is fair game during post confrence for the instructor to ask - Arghhh and its usually the 1 thing I forgot to write down that Im asked about.

In your clinical packet do they give you assessment forms that you write down all the pertinent info on. We have these forms that you do all of your assessments on and then you would have space on the back to keep all that other info.

  • Author

Trusen- thanks for posting those 2 forms. We did not receive any kind of forms - my class mates and I have been working on building our own assessment and shift report forms - :uhoh3:

  • Experts

try checking out some of the links at these sites for a form you might find useful for your clinicals.

http://www.csufresno.edu/nursingstudents/fsnc/clinicalforms.htm

http://healthscience.cypresscollege.edu/~rn/rnforms.shtml

often it is most efficient to just develop your own. some years ago i started using the table menu in word to develop report sheets for work and have learned how to use the formatting so well that i can create just about any kind of form i need if i can sketch it out on a piece of paper.

at this thread https://allnurses.com/forums/f50/report-sheet-149277.html you will find my attachment for my report sheet that i currently use as well as someone elses. it has some of the elements you need. feel free to copy and use it.

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