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PCD 2 mental
Pcd for mental
Course
Mental-Health Nursing (NR-326)
826 Documents
Students shared 826 documents in this course
University
Chamberlain University
Academic year: 2024/2025
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Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661
Level 3 Clinical Courses Page 1 of 10
Student Name: D#: Date:
Course: Session: Year:
DIRECTIONS
This Direct Patient Care Documentation must be completed for one patient whom you are providing direct care in a clinical learning
setting. Information within this packet can be handwritten or typed (with the exception of the reflection journal) and must be reviewed
with your faculty on your assigned clinical day and submitted within 24 hours (or as directed by course leader). If additional space is
needed, please use the back of each page. If any area within this packet was not performed, line out and place “N/A” in that section.
- Grading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the clinical learning evaluation.
Satisfactory rating meets the following:
- Clinical Learning Competency: Completes all clinical learning experiences and requirements successfully (PO 5).
- Performance Descriptor: Completes all assignments related to the clinical learning experience within established guidelines.
- I-SBAR: Utilized for receiving report. Areas that indicate clinical significance are to be completed after patient report has been
received. Students should deliver a hand-off report at the end of their shift to the bedside nurse.
- Assessment Findings, Nursing Notes, Labs/Diagnostics, and Healthcare Provider Orders: Complete according
to your assigned patient.
- Medication Information: List and complete the information for each medication your patient is ordered.
- Clinical Judgment Measurement Model (CJMM): Complete reflecting on all the data/cues (Assessment, Labs/Diagnostics,
Prescriptions/Orders and Patient Information) from your assigned patient.
- Concept Map: Complete reflecting on all the information and assessment findings gathered from your assigned patient.
- Reflection Journal – Complete a reflection journal and submit to your faculty (or as directed) within 24 hours of completing your
clinical learning experience. Reflective journaling provides a format to share your knowledge, skills, experiences and personal
reflection related to concepts and strategies learned throughout your program. What could you or did you delegate and to whom?
Include ways you plan to care for yourself throughout your program. The reflection journal is required to be a typed Word document,
Times New Roman 12 - point font and minimum of one page and no more than three pages.
At least one time during the session, faculty will select one of the following questions for you to reflect on.
1. Describe how racial/health disparities, health equality/inequality, and social justice/injustice could apply to the clinical
site/agency’s community. Consider the population and determine why this may be occurring.
2. Transportation and housing are drivers of health and equity. Describe the steps you would take as a nurse to evaluate
transportation and housing for your identified community population and what actions you could perform to identify resources.
3. How can nurses be change agents and advocate for their community? Provide at least two specific examples.
Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661
Level 3 Clinical Courses Page 2 of 10
I-SBAR
I – Introduce Yourself
Your Name:
D#:
Your Title:
Reason for being there:
S – Situation
Patient: Attending Physician:
Age: Patient Chief Complaint/Primary Medical Diagnosis
and Clinical Significance:
Gender/Identity:
Height/Weight:
Allergies:
Code Status:
Advance Directive (durable power of attorney,
living will, other) and Clinical Significance:
Pathophysiology of Primary Medical Diagnosis:
Privacy Code:
Date of Care/Time:
B – Background
Include clinical significance with each:
Past Medical History: Past Surgical History:
Immunizations Received:
Social History/Socioeconomic Factors:
A – Assessment
Vital Signs:
B/P HR RR TEMP SP0 2 PAIN
Fall Risk: Accu-check:
IV Site: IV Fluids: Lab/Test Results:
I and O
Isolation Isolation Precautions: Y ☐ N ☐ Contact Air ☐ Droplet ☐
RESPIRATORY
CARDIOVASCULAR
NEUROLOGICAL
GI/GU
INTEGUMENTARY
PSYCHOLOGICAL
FAMILY – SUPPORT
SAFETY
Teaching needed:
Quality in Safety Education Nurses (QSEN) Risk(s) Identified:
R – REQUEST/
RECOMMENDATION
Hand off report to: From:
Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661
Level 3 Clinical Courses Page 4 of 10
NURSING NOTES
Date/Time Nursing Note
Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661
Level 3 Clinical Courses Page 5 of 10
Telemetry Rhythm Strip
If applicable: Attach your patient’s rhythm strip below and determine the following information:
PRI: QRS: QT: Rate: Rhythm:
What assessment findings/cues are associated with your patient’s rhythm?
Identify the priority treatment based on your assessment findings (cues) and how you would evaluate for effectiveness.
LABS & DIAGNOSTICS
Test Result/ Date Norm Reason out of norm/reason for drawing if normal or N/A if not drawn
WBC
RBC
Hgb
Hct
Plt
Chol
Trig
LDH
PT
APTT
AST
ALT
Tdl*
Test Result/ Date Norm Reason out of norm/reason for drawing if normal or N/A if not drawn
Glu
BUN
Na
K
Cl
Creat
CO 2
Ca
Phos
Mag
T. Pro
Alb
Tdl*
What patient findings and interventions would you anticipate with these laboratory/diagnostic findings?
- Therapeutic drug level
Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661
Level 3 Clinical Courses Page 7 of 10
####### ASSESSMENT ANALYSIS PLANNING IMPLEMENTATION EVALUATION
THE CLINICAL JUDGMENT MEASUREMENT MODEL
The Clinical Judgment Measurement Model (CJMM) identifies six cognitive skills needed to make appropriate clinical judgments.
Complete the following section using the CJMM and reflecting on all the data/cues (Assessment, Labs/Diagnostics, Prescriptions/Orders
and Patient Information) from your assigned patient.
RECOGNIZE
CUES
ANALYZE
CUES
PRIORITIZE
HYPOTHESIS
GENERATE
SOLUTIONS
TAKE
ACTION
EVALUATE
OUTCOMES
Recognize Cues – Identify relevant and important information from different sources (e., medical history, vital signs).
List the data/cues that are
relevant and are interpreted
as clinically significant.
Significant Significant Significant Significant Significant
Data/Cue 1 Data/Cue 2 Data/Cue 3 Data/Cue 4 Data/Cue 5
Analyze Cues – Organizing and linking the recognized cues to the patient’s clinical presentation.
Interpret the relevant
clinical data/cues.
Identify the top three
most likely problems.
Is additional data needed
to confirm the clinical
significance of the cues
at this point? Be specific;
what additional data
is needed to confirm?
Potential Problem 1 Potential Problem 2 Potential Problem 3
Additional Data Additional Data Additional Data
Prioritize Hypothesis – Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk, difficulty, time, etc.).
Of the potential problems
you identified, which
problem(s) is most likely
present? Which problem
is the most concerning
and why?
Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661
Level 3 Clinical Courses Page 8 of 10
Generate Solutions – Identifying expected outcomes and using hypotheses to define a set of interventions for the expected outcomes.
Based on the most
urgent problem,
what are the priority
actions/interventions?
For each priority
action, what are the
desired outcomes?
Priority Action/Intervention 1 Priority Action/Intervention 2 Priority Action/Intervention 3
Expected Outcomes Expected Outcomes Expected Outcomes
Are there any
interventions or actions
that should be avoided?
Include rationale.
Take Action – Implementing the solution(s) that addresses the highest priorities.
How should the
interventions or actions
above be accomplished?
(Performed, administered,
requested, communicated,
taught, documented, etc.).
List environmental
and/or individual factors
impacting the ability
of the nurse to generate
solutions and take action.
Environmental
Factor 1
Individual
Factor 1
Environmental
Factor 2
Individual
Factor 2
Environmental
Factor 3
Individual
Factor 3
Evaluate Outcomes – Comparing observed outcomes against expected outcomes.
Compare observed outcomes to expected outcomes – has the patient’s status improved, declined or remain unchanged?
Does the observed
outcome match
expected outcome? If not,
what are the additional
actions/interventions that
should be considered?
Observed Outcomes Observed Outcomes Observed Outcomes
Matches Expected Outcome? Matches Expected Outcome? Matches Expected Outcome?
If the patient status has
not improved, what other
issues may be present?
List environmental
and/or individual
factors impacting
the achievement
of outcomes.
Environmental
Factor 1
Individual
Factor 1
Environmental
Factor 2
Individual
Factor 2
Environmental
Factor 3
Individual
Factor 3
Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661
Level 3 Clinical Courses Page 10 of 10
MEDICATION INFORMATION
Med Rec Completed: Y ☐ N ☐
Med Name Med Classification Rationale for Med Home, Current, or New Med Time Due Contraindications/ Interactions
Nursing
Complications,
Interventions
& Considerations
Patient Education
Was this document helpful?
PCD 2 mental
Course: Mental-Health Nursing (NR-326)
826 Documents
Students shared 826 documents in this course
University: Chamberlain University
Was this document helpful?
Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 1300 | Chicago, IL 60661
©2023 Chamberlain University LLC. All rights reserved.
12-180405.4
0723pflcpe
Clinical Learning – Direct Patient Care Documentation
Level 3 Clinical Courses
Page 1 of 10
Student Name: D#: Date:
Course: Session: Year:
DIRECTIONS
This Direct Patient Care Documentation must be completed for one patient whom you are providing direct care in a clinical learning
setting. Information within this packet can be handwritten or typed (with the exception of the reflection journal) and must be reviewed
with your faculty on your assigned clinical day and submitted within 24 hours (or as directed by course leader). If additional space is
needed, please use the back of each page. If any area within this packet was not performed, line out and place “N/A” in that section.
• Grading: Evaluated as Satisfactory, Unsatisfactory or Needs Improvement on the clinical learning evaluation.
Satisfactory rating meets the following:
– Clinical Learning Competency: Completes all clinical learning experiences and requirements successfully (PO 5).
• Performance Descriptor: Completes all assignments related to the clinical learning experience within established guidelines.
• I-SBAR: Utilized for receiving report. Areas that indicate clinical significance are to be completed after patient report has been
received. Students should deliver a hand-off report at the end of their shift to the bedside nurse.
• Assessment Findings, Nursing Notes, Labs/Diagnostics, and Healthcare Provider Orders: Complete according
to your assigned patient.
• Medication Information: List and complete the information for each medication your patient is ordered.
• Clinical Judgment Measurement Model (CJMM): Complete reflecting on all the data/cues (Assessment, Labs/Diagnostics,
Prescriptions/Orders and Patient Information) from your assigned patient.
• Concept Map: Complete reflecting on all the information and assessment findings gathered from your assigned patient.
• Reflection Journal – Complete a reflection journal and submit to your faculty (or as directed) within 24 hours of completing your
clinical learning experience. Reflective journaling provides a format to share your knowledge, skills, experiences and personal
reflection related to concepts and strategies learned throughout your program. What could you or did you delegate and to whom?
Include ways you plan to care for yourself throughout your program. The reflection journal is required to be a typed Word document,
Times New Roman 12-point font and minimum of one page and no more than three pages.
At least one time during the session, faculty will select one of the following questions for you to reflect on.
1. Describe how racial/health disparities, health equality/inequality, and social justice/injustice could apply to the clinical
site/agency’s community. Consider the population and determine why this may be occurring.
2. Transportation and housing are drivers of health and equity. Describe the steps you would take as a nurse to evaluate
transportation and housing for your identified community population and what actions you could perform to identify resources.
3. How can nurses be change agents and advocate for their community? Provide at least two specific examples.
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