Scribd Logo
Upload

Welcome to Scribd!

  • 111 views

    1 Daily Clinical Log

    Uploaded by

    I
    This document contains a clinical log template for nursing students to document information about a patient's health assessment, care, and treatment. The log includes sections for demographic data, health characteristics, vital signs, reason for admission, medical history, physical exam findings, current medications, lab results, intake/output, health teachings, documentation, and the nursing process. The log provides a comprehensive way for students to track all relevant health factors and the care provided to a patient during clinical training.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    1 Daily Clinical Log

    Uploaded by

    I
    111 views7 pages
    This document contains a clinical log template for nursing students to document information about a patient's health assessment, care, and treatment. The log includes sections for demographic data, health characteristics, vital signs, reason for admission, medical history, physical exam findings, current medications, lab results, intake/output, health teachings, documentation, and the nursing process. The log provides a comprehensive way for students to track all relevant health factors and the care provided to a patient during clinical training.

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document contains a clinical log template for nursing students to document information about a patient's health assessment, care, and treatment. The log includes sections for demographic data, health characteristics, vital signs, reason for admission, medical history, physical exam findings, current medications, lab results, intake/output, health teachings, documentation, and the nursing process. The log provides a comprehensive way for students to track all relevant health factors and the care provided to a patient during clinical training.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    111 views7 pages

    1 Daily Clinical Log

    Uploaded by

    I
    This document contains a clinical log template for nursing students to document information about a patient's health assessment, care, and treatment. The log includes sections for demographic data, health characteristics, vital signs, reason for admission, medical history, physical exam findings, current medications, lab results, intake/output, health teachings, documentation, and the nursing process. The log provides a comprehensive way for students to track all relevant health factors and the care provided to a patient during clinical training.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 7

    KINGDOM OF SAUDI ARABIA ‫المملكة العربية السعودية‬

    Ministry of Higher Education ‫وزارة التعليم العال‬


    University of Hail
    College of Nursing ‫جامـعـة حـائل‬
    ‫كلية التمريض‬

    CLINICAL LOG

    Student Name

    University Number

    Instructor Name

    Health Assessment
    A. Demographic Data
    Patient Name Ward

    Age Marital Status Room


    Gender Occupation Bed Number

    B. Health Characteristics
    Height(cm) Date of Admission

    Weight(kg) Surgical Intervention

    Body Mass Index Date of Surgery

    Medical Diagnosis:
    Definition

    Causes

    C. Hemodynamic Baseline
    Temperature Blood Pressure

    Pulse Rate Mean Arterial Pressure(MAP


    Respiratory Rate Central Venous Pressure(CVP)

    SPO2 Others:

    D. Reason for Admission (Chief Complaint)


    KINGDOM OF SAUDI ARABIA ‫المملكة العربية السعودية‬
    Ministry of Higher Education ‫وزارة التعليم العال‬
    University of Hail
    College of Nursing ‫جامـعـة حـائل‬
    ‫كلية التمريض‬

    CLINICAL LOG

    E. Past Medical or Surgical History

    F. Physical Examination
    Technique Findings
    Inspection

    Percussion

    Palpation

    Auscultation

    G. Current Medications
    Date Name of Drug Route, Dosage Classification Indication Side Effects Nursing
    ,Frequency Considerations
    KINGDOM OF SAUDI ARABIA ‫المملكة العربية السعودية‬
    Ministry of Higher Education ‫وزارة التعليم العال‬
    University of Hail
    College of Nursing ‫جامـعـة حـائل‬
    ‫كلية التمريض‬

    CLINICAL LOG

    DRUG COMPUTATION
    KINGDOM OF SAUDI ARABIA ‫المملكة العربية السعودية‬
    Ministry of Higher Education ‫وزارة التعليم العال‬
    University of Hail
    College of Nursing ‫جامـعـة حـائل‬
    ‫كلية التمريض‬

    CLINICAL LOG
    H. Laboratory Results & Diagnostic Procedures
    Date Test Results Normal Value Interpretation Nursing
    Considerations

    H.1 DIAGNOSTIC/ IMAGING TEST


    Date Test Results/ Interpretation Nursing Considerations

    I. Intake and Output


    Time Intake Output Others
    Oral/N IV NGT BT Urine NGT Drainage

    TOTAL
    BALANCE
    KINGDOM OF SAUDI ARABIA ‫المملكة العربية السعودية‬
    Ministry of Higher Education ‫وزارة التعليم العال‬
    University of Hail
    College of Nursing ‫جامـعـة حـائل‬
    ‫كلية التمريض‬

    CLINICAL LOG

    IV computation:

    J. Health Teachings

    K. Documentation

    Teacher’s
    Date/ Time FOCUS Nurse’s Notes
    Remarks

    Signature:
    Title:
    KINGDOM OF SAUDI ARABIA ‫المملكة العربية السعودية‬
    Ministry of Higher Education ‫وزارة التعليم العالي‬
    University of Ha’il ‫جامـعـة حـائل كلية‬
    College of Nursing ‫التمريض‬

    L. Nursing Process
    Assessment/Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation
    (Prioritize)
    Subjective Data:

    Objective Data:

    5 Page
    ____________________________________________________
    For Evaluators 3 Ideal The student's answer exceeds expectations. All information needed based on patient-specific health needs are provided.
    only 2 Acceptable The student satisfactorily provided the information needed based on patient-specific health needs. The student answer/
    entry is partially correct/ lacking or incomplete.
    1 Poor The student did not provide an answer. Incorrect answer/ entry.

    No. Items for Evaluation Score

    1 A. DEMOGRAPHIC DATA
    2 B. HEALTH CHARACTERISITICS
    3 C. HEMODYNAMIC BALANCE
    D. REASON FOR ADMISSION (CHIEF
    4
    COMPLAINT)
    5 E. PAST MEDICAL OR SURGICAL HISTORY
    6 F. PHYSICAL EXAMINATION
    7 G. CURRENT MEDICATION
    8 G.1 COMPUTATION
    H. LABORATORY RESULTS AND DIAGNOSTIC
    9
    PROCEDURES
    10 I. INTAKE AND OUTPUT
    11 I.1 COMPUTATION
    12 J. HEALTH TEACHING
    13 K. DOCUMENTATION
    14 L Nursing Process

    RAW SCORE/ TOTAL # OF ITEMS x 15 =

    Checked by:

    ____________________________________________
    Field Teaching Staff Name and Signature / Date

    6 Page

    You might also like