Students, show me your clinical paperwork!

[erika.RN]

Hi all, I am a clinical preceptor for the junior level. I am teaching med-surg clinicals and trying to figure out the best clinical paperwork/assignments for my students for post clinical. I am hoping to explore new care plan options. I would love to see what you all are using and what your requirements are. Currently I expect a care plan with a patho, 2 nursing dx care plan and SBAR report. Anyone willing to share? If email would be easier, please let me know.

Thanks for your help!

[alwayslulu]

We are required 3 nursing diagnoses, 1 patho diagram, assessment sheets, and medication sheets with all the drug info.

[imhorsemackerel, LPN]

For LPN school, we were lucky. Even though every week we got a new patient, we only had to make two care plans. We needed to collect data for all of the body systems (CV, GI, GU, integumentary, etc) as well as vitals, IV, psychosocial issues, mobility. Based on the data collected, we needed to come up with the best NANDA for each of these categories. Then we needed to pick the 5 most important issues and put them in order. Each had to have the R/T and AEB. I believe each needed 5 intervention and one goal (we had to pretend if the goal was met or not and note in). The patients often had several diagnoses, so the instructor would pick one for each of us to look up. We needed to write a short paper with at least 3 reputable references that described the patho. We also had at least 5 med sheets. There was also a sheet where we would have to write a brief description of all of the tests that were being performed on the patient (labs,diagnostic) or the surgery, normal and abnormal findings.

We never really had to do the SBAR, but the last page pretty much required us to interpret our findings (since we couldn't assess), and recommendations along with our rationales. Looking back, doing the actual SBAR would've helped me now.