PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Student Name: Richard Boateng Week: Dates of Care:07/24/21
Patient Initials

B.A

Sex

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Female

Age

78

Room

1514/01

Admitting Date

07/15/21

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Patient present with irregular heart rate.

 

Attending physician/Treatment team:

Hakim Ibrahim

 

Consults:
Present Diagnosis: (Why patient is currently in the hospital)

Aterial fibrillation with RVR (SMC-HCC)

 

ER Management: (if applicable)

 

Allergies:

Patient has no Allergies

 

Code Status:

Full code

Isolation: (type and reason)

No isolation

Admission Height:

5’’6

 

Admission Weight:

156 pounds/12 ounce

Arm Band Location (colors & reasons)

Clear and+

 

Communication needs: (verbal, nonverbal, barriers, languages)

English, verbal

 

Past Medical History: (pertinent & how managed)

PMH: stage iv squamous cell lung cancer on ipi/nivo, DM2, HLD , CAD MI (2003)

 

Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)

 

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

 

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Time

0948

T

97.8

P

83

R

18

B/P

117/69

Time

1640

T

96.7F

P

88

R

18

B/P

11050

 

GI:

Diet:

Swallow precautions:

Tube feedings:

NG / G tube:

Blood Glucose: (time & date)

Last bowel movement: (time & date)

Pertinent Labs/Test:

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

 

Respiratory:

02 modalities:

02 Saturation:99%

Suction:

Resp Rx’s:

Trach:

Chest Tubes:

Pertinent Labs/Test:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

 

Neurosensory:

Neuro checks:

Alert & Orientated:

Follows commands:

Speech Comprehensible:

Pertinent Labs/Test:

Assessments/Interventions:

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)

Cardiovascular:

Telemetry:

Pacemaker/IAD:

DVT Prevention:

Daily Weights:

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)

 

Musculoskeletal:

Activity:

Traction:

Casts/Slings:

Pertinent Labs/Test:

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps

 

Renal:

Catheter (indwelling/external):

CBI:

Dialysis:

A/V access:

Pertinent Labs/Test:

Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

 

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)

 

Pain:

Pain score:

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

 

Vascular Access: (IV site)

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)

 

Gyn:

Gravida/Para:

LMP:

Last Pap:

Breast exam:

Pertinent Labs/Test

Assessment/Interventions: (bleeding, discharge)

 

Post-operative /procedural:

Assessments/Interventions:

(immediate post procedure care)

 

Safety:

Call light:

Bed Rails:

Bed alarms:

Fall risk:

Assistive Devices:

Sitter use:

Restraints (type, duration & reason):

Assessment/Interventions (modifications to room, environment, Patient)

 

Advance Directives/Ethical considerations:

DPOA:

Hospice:

 

Pertinent Data (Labs, X-rays, Etc.)

Results

Normal Lab Values

Significance to your patient