Question Description
School of Health Professions, Science and Wellness
Department of Nursing
Daily Clinical log
Spring 2017
Course: __________________________________________________________________________
Student: _________________________________ Date: _____________________________
Client’s Initials: ___________ Age: _________ Sex: ________ Room#: ________________
Date of Admission: ________________ Date of Care: _____________________________
Present Medical Diagnoses: ____________________________________________________
Present Surgery (if applicable): _____________________ Date of Surgery: ______________
Allergies: __________________________ Code Status: ________________________
Vital Signs T_____________ P_____________ R____________ BP______________ SPO2___________
General Appearance
Psychiatric
HEENT
Neck
Breasts
Lymph Nodes
Pulmonary
Cardiovascular
Skin
Nails
Abdomen
Genitourinary
Pelvic
Rectal
Extremities
Musculoskeletal
Neurological (DTR’s, reflex grading, cranial nerve evaluation)
Incisions
Drains
Diet/Nutrition
IVs
Intake and Output
Fall Risk Assessment (include score)
Pressure Ulcer Risk Assessment (include score)
Pain assessment (include reassessment)
| Time | Score | Intervention | Reassessment Time | Score |
Diagnostic Assessments – Important EKGs, X-Rays, and Labs
| Lab/Other Test | Patient values | Inference |
Medications Administered:
| MedicationsDose/Brand name/Generic name | Indication of use | Adverse Effect/Side effect | Nursing Implications | |
| Treatments and Procedures | Day & Times | Rationale |
Nursing Interventions:
| Assessment Findings | Nursing Diagnosis | Outcome | Nursing Interventions | Evaluations |
Reflections of the day on meeting course objectives:
