What This Document Is
This is a Direct Patient Care Documentation form used by students in the Chamberlain University Adult Health II (NR 325) course. It’s designed to be completed during clinical rotations where students are providing hands-on care to patients. The form is a structured way to record observations, assessments, and interventions.
Why This Document Matters
This form is essential for nursing students completing clinical requirements. It serves as a record of their direct patient care activities, demonstrating their application of learned skills and knowledge. Faculty use this documentation to evaluate student competency and provide feedback. It’s submitted within 24 hours of the clinical session.
Common Limitations or Challenges
This document is a *record* of care, not a teaching tool. It requires pre-existing knowledge of nursing assessments, procedures, and pharmacology. It doesn’t provide instruction on *how* to perform these tasks.
What This Document Provides
The full document includes sections for:
* Patient information and session details
* I-SBAR report completion
* Assessment findings and lab/order documentation with rationale
* ATI Active Learning Template requirements (Diagnostic Procedure, Therapeutic Procedure, Nursing Skill, and Medication templates)
* Nursing diagnosis prioritization and concept mapping
* A reflection journal for self-assessment.
This preview *does not* include the actual templates or space to complete patient-specific information. It is a blank form awaiting clinical application.
