This document is a Direct Patient Care Documentation form for Chamberlain University’s NUR 1211 Medical Surgical Nursing course at Miami Dade College. It’s designed for Level 3 clinical courses and requires handwritten completion (except for a separate reflection journal) for one patient receiving direct care.
This form is essential for students completing clinical rotations, as it serves as a record of patient assessment, care planning, and interventions. It’s submitted to faculty for review within 24 hours of the clinical experience. It’s intended to demonstrate competency in direct patient care and documentation skills.
This document *does not* provide medical advice or complete patient care; it’s a tool for *recording* care provided under faculty supervision. It also doesn’t include completed templates or the reflection journal itself.
The full document includes sections for: I-SBAR patient report, healthcare provider orders, ATI Active Learning Templates (Diagnostic Procedure, Therapeutic Procedure, Nursing Skill, and Medication), nursing diagnoses with a concept map for the top priority diagnosis, and space for a typed reflection journal. It specifically focuses on a patient named Butch Sampson with cellulitis and Type 2 diabetes.
