What This Document Is
This is a completed Short Form Care Planning Tool, specifically utilizing a RAM (Recall, Assess, Monitor) assessment of behaviors and stimuli, completed by student Jangung Kim on March 18, 2023, for client A.B., an 81-year-old patient with a primary diagnosis of dementia. It represents a snapshot of a nursing assessment performed during a clinical assignment at Jersey College Nursing School.
Why This Document Matters
This completed form is intended for Jersey College Nursing School students and instructors. It serves as an example of how to document a focused assessment and care planning process for geriatric patients, particularly those experiencing cognitive decline. It’s used for evaluating a student’s ability to apply theoretical knowledge to a real-world clinical scenario.
Common Limitations or Challenges
This document is a single, completed example. It does not provide instruction on *how* to complete the form, nor does it cover all possible patient presentations or care plans. It is a demonstration of assessment findings for one patient at one point in time.
What This Document Provides
The document includes a completed RAM assessment covering vital signs, past medical/surgical history, medication list, GI/Nutrition assessment, neurological assessment, respiratory assessment, cardiovascular assessment, and skin assessment. It also includes documented findings for each assessment area. This preview *does not* include the full scope of the student’s clinical reasoning or the complete care plan developed based on these findings.