This document is a Level 3 Direct Patient Care Documentation form used in the Chamberlain University NR 324 Adult Health course. It’s designed for students to record and submit details from a clinical learning experience where they provide direct patient care.
This form is essential for students completing clinical rotations, as it demonstrates their ability to assess patients, document findings, understand healthcare orders, and apply nursing concepts. It’s submitted to faculty for review and evaluation of clinical competency. This assignment is due within 24 hours of the clinical experience, or as directed by the course coordinator.
This document *does not* provide clinical instruction or patient care guidelines. It’s a recording tool, not a teaching resource. It requires students to *apply* knowledge gained elsewhere.
The full document includes sections for: patient demographics, SBAR communication framework, assessment findings across multiple body systems, documentation of diagnostic and therapeutic procedures, medication administration details (with Active Learning Templates), nursing diagnoses (including a concept map for the priority diagnosis), and a reflective journal. It also provides a table of medications with clinical significance to be documented. This preview does not include the Active Learning Templates or the reflective journal prompt.