Direct Patient Care Documentation Susan Jackson.docx - 1...

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1 Clinical Learning Direct Patient Care Documentation Sept/2020
2 Table of Contents NR 226 DIRECT PATIENT CARE DOCUMENTATION Submit in the Weekly CLA drop box each virtual clinical day May be hand written or typed I-SBAR on iHuman patient for the virtual clinical day ..................................................................................... 3 Nursing Skill ALT (Use ALT template to complete) .......................................................................................... 4 Healthcare Provider Orders ....................................................................................................................... 5 &6 Concept Map ................................................................................................................................................. 7 Reflection paper (1 paragraph only) ……………………………………………………………………………………………………………8 Nurses Note (already completed in the iHuman) ……………..…………………………………………………………………………8 Sept/2020
3 Sept/2020 B/P HR RR TEMP SP02 PAIN 124/82 70bpm 20 98.6 F. 96% RA 3/10 on dressing I Introduce yourself Your Name: Jimmy Yip Your Title: Student Nurse Reason for being there: Patient Assessment S Situation Patient: Susan Jackson Age: 66 y/o Gender: Female Height/Weight: 168cm/109.1kg Allergies: No known allergies Code status: Full Privacy Code: Apple Time: 08:00 Attending Physician: Dr.Wellman Patient Chief Complaint: Poor wound healing of right below knee amputation Admitting Diagnosis: Poor wound healing of right below knee amputation Admission Date: 9/19/20 B Background Past Medical History : Uncontrolled T2 diabetes Diabetic neuropathy Hyperlipidemia Obesity Hypertension PAD Social History: Father died of MI age 62 Mother died of breast cancer age 68 3 brothers all with T2 diabetes and “heart” problems.

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