Posted: July 30th, 2023

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET

Student Name: Week: Dates of Care:

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Demographics and Brief History
Patient Initials Sex Age Room Admitting Date Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?
Attending physician/Treatment team: Precautions:
Primary Diagnosis: Co-morbidities:
Allergies: Code Status: Isolation: (type and reason)
Admission Height: Admission Weight: Arm Band Location (colors & reasons)
Past Medical History: (pertinent & how managed)
Significant Events during this hospitalization but not during this clinical time: (examples include restrictive interventions or any medical emergencies. Include date, event and outcome)

Physical Assessments and Interventions: (Include all pertinent data)
Vital signs:
General Appearance
• Grooming/Clothing
o
• Hygiene
o
• Posture
o
• Gait
o
• Obese/average or normal/ underweight
o
• Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings
o Activities of Daily Living
• Sleep/rest
o
• Diet
o
• Exercise/mobility
o
• Elimination
o
• Hygieneo
GI
Diet:
Blood Glucose (time & date):
Last bowel movement (time & date): Pertinent Labs/Test:
Assessments:
• Stool
o
• Bowel soundso Respiratory:
Assessments:
• Lung sounds
o
• Cough, sputum
o
• SOB
o
Interventions:

• Tenderness, distention
o
• Appetite, nausea, vomiting
o
Interventions:
Neurosensory: Alert & Orientated: Follows commands:
Speech Comprehensible: Pertinent Labs/Test: Assessments:
• LOC Cardiovascular:
Pertinent Labs/Test: Assessments
• Peripheral pulses
o
• Heart sounds (murmurs or bruits)
o
• Edema
o
• Chest pain, discomfort, palpitations
o
Interventions:
o
• Pupils
o
• Glascow Coma Scale
o
• Dizziness
o
• Headaches
o
• Tremors
o
• Tingling, weakness, paralysis, or numbness
o
Interventions:
Musculoskeletal:
Activity:
Casts/Slings:
Assessments:
• Strength, weakness
o
• ROM
o
• Gait (documented under appearance)
• Pain Renal:
Pertinent Labs/Test: Assessments:
• Bruit, thrill, location
o
• Urine-quality
o
• Burning with urination, hematuria
o
• Incontinent, continent, I & O
o o
Interventions:

• Fractures, amputations, or transfers
o
Interventions:
Skin:
Braden Score: Pertinent Labs/Test: Assessments
• Bruising, wounds, drains Pain:
Pain score: Assessments/Interventions:
• Scale used
o
• Location, duration, intensity, character
o
• Exacerbation, relief
o
Interventions:
o
o
• Turgor
o
• Surgical incisions
o
• Finger & toe nails
o
Interventions:
Gyn: Gravida/Para: LMP:
Last Pap: Breast exam:
Pertinent Labs/Test: Assessment
• Bleeding Safety:
Bed Rails: Bed alarms: Fall risk:
Assistive Devices: Interventions:
o
o
• Discharge
o
Interventions:
Advance Directives/Ethical considerations:

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AD:
POA:

Lab Values Results Normal Lab Values Significance to your patient (if applicable)
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
Platelets
RDW
MPV
Glucose
BUN
Creatinine
Sodium
Potassium
Cloride
Calcium
Salicylate

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Please add lab values for any medications that may require a blood draw (e.g., Lithium, Lamotrigine, Carbamazepine, Oxcarbazepine, Sodium valproate/divalproex sodium)

10 Panel Toxicology/Drug Screen: if available
Lab Value Results Normal Lab
Values Significance to your patient (if applicable)

Lab Value Results Normal Lab
Values Significance to your patient (if applicable)

Psycho/Social Assessment
• Level of education
o
• Occupation
o
• Race/Ethnic Background or Identification
o
• Religion/Spiritual Beliefs
o
• Communication needs: (verbal, nonverbal, barriers, languages)
o
• Special Talents/Interests/Skills
o
• Environment (home and community)
o
• Family Structure/History:
Stage of Development: (Erikson’s Stage of Development, describe the current stage of the client and previous stages that the client may not have successfully completed)
Support System:
Stressors/Stress Management Practices:

Pathophysiological Discussion: One scholarly article must be cited using APA format in this section. The textbook may also be used as a secondary source. The reference list should be included with the
summary of the article.
Discuss the current disease process:
Discuss the etiology of the patient’s illness:
Also note the complications that may occur with treatments and patient’s overall prognosis:
Attach a research article pertaining to diagnosis of patient. Write a summary about the article below and include a reference list:

.

References

Medications
Classification
Dose
Route
Freq
Purpose/Mechanism of Action
Significant Side Effects / Adverse Reactions
Nursing Implications

Medications
Classification
Dose
Route
Freq
Purpose/Mechanism of Action
Significant Side Effects / Adverse Reactions
Nursing Implications

Nursing Process Section

Nursing Diagnosis:
List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting.

Priority Nursing Diagnosis Related to As Evidence By Rationale (reason for priority)
1
2
3
4

Complete a table for the top two priorities listed in the table above. A minimum of 3 interventions are required for each nursing diagnosis, and one intervention must be an individual patient teaching and one must include a teaching for the patient’s family/caregivers (if applicable- i.e., patient is not homeless and/or has no family).

Table for Nursing Diagnosis Number 1

Assessment

• Signs and symptoms relative to the nursing diagnosis, as evidence by

o 2 objective
o 2 subjective
Patient Outcome
Interventions/Implementations
Evaluation
• SMART
o Specific
o Measurable
o Attainable
o Realistic
o Timely • Includes interventions/ nursing actions directly relating to pt. outcomes
• Specific in action, frequency and contain rationale
• Minimum of 3 interventions appropriate to help pt./ family meet their outcomes • Includes all data that is listed as criteria in outcomes
• Outcomes are determined to be met, partially met, or not met
• If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

Table for Nursing Diagnosis Number 2

Assessment

• Signs and symptoms relative to the nursing diagnosis, as evidence by

o 2 objective
o 2 subjective
Patient Outcome
Interventions/Implementations
Evaluation
• SMART
o Specific
o Measurable
o Attainable
o Realistic
o Timely • Includes interventions/ nursing actions directly relating to pt. outcomes
• Specific in action, frequency and contain rationale
• Minimum of 3 interventions appropriate to help pt./ family meet their outcomes • Includes all data that is listed as criteria in outcomes
• Outcomes are determined to be met, partially met, or not met
• If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

patient has depressions accordingly, page 2-4 say no abnormal symptoms
ChatGPT
Patient/Client Data - Clinical Decision-Making Worksheet

Student Name: [Your Name]
Week: [Week Number]
Dates of Care: [Date Range]

Demographics and Brief History

Patient Initials:
Sex:
Age:
Room:
Admitting Date: [Date]
Admitting Chief Complaint: [Briefly describe the symptoms that caused the patient to come to the hospital.]

Attending physician/Treatment team:
Precautions:

Primary Diagnosis:
Co-morbidities:
Allergies:
Code Status:
Isolation: [Specify the type and reason for isolation, if applicable.]

Admission Height:
Admission Weight:
Arm Band Location: [Specify colors & reasons, if applicable.]

Past Medical History: [Briefly describe the pertinent medical history and how it has been managed.]

Significant Events during this hospitalization but not during this clinical time: [Include examples such as restrictive interventions or medical emergencies with date, event, and outcome.]

Physical Assessments and Interventions

Vital signs:
General Appearance
• Grooming/Clothing
• Hygiene
• Posture
• Gait
• Body Mass Index (BMI)
• Evidence of scars/abrasions/bruises/tattoos/physical markings

Activities of Daily Living
• Sleep/rest
• Diet
• Exercise/mobility
• Elimination
• Hygiene

GI
Diet:
Blood Glucose (time & date):
Last bowel movement (time & date):

Pertinent Labs/Test:
Assessments:
• Stool
• Bowel sounds

Respiratory:
Assessments:
• Lung sounds
• Cough, sputum
• Shortness of breath (SOB)

Interventions:

Neurosensory:
Alert & Orientated: Follows commands:
Speech Comprehensible:

Pertinent Labs/Test:
Assessments:
• Level of Consciousness (LOC)

Cardiovascular:
Pertinent Labs/Test:
Assessments:
• Peripheral pulses
• Heart sounds (murmurs or bruits)
• Edema
• Chest pain, discomfort, palpitations

Interventions:

Musculoskeletal:
Activity:
Casts/Slings:
Assessments:
• Strength, weakness
• Range of Motion (ROM)
• Gait
• Pain

Renal:
Pertinent Labs/Test:
Assessments:
• Bruit, thrill, location
• Urine quality
• Burning with urination, hematuria
• Incontinent, continent, I & O

Interventions:

Skin:
Braden Score:
Pertinent Labs/Test:
Assessments:
• Bruising, wounds, drains

Pain:
Pain score:
Assessments/Interventions:
• Pain scale used
• Location, duration, intensity, character
• Exacerbation, relief

Gynecological:
Gravida/Para:
Last Menstrual Period (LMP):
Last Pap:
Breast exam:
Pertinent Labs/Test:
Assessment:
• Bleeding

Safety:
Bed Rails:
Bed alarms:
Fall risk:
Assistive Devices:
Interventions:

Advance Directives/Ethical Considerations:
AD:
POA:

Lab Values:
[Include relevant lab values and their significance to the patient's condition, if applicable.]

Psycho/Social Assessment:

• Level of education
• Occupation
• Race/Ethnic Background or Identification
• Religion/Spiritual Beliefs
• Communication needs: (verbal, nonverbal, barriers, languages)
• Special Talents/Interests/Skills
• Environment (home and community)
• Family Structure/History
• Stage of Development: [Describe the current stage of the client and previous stages that the client may not have successfully completed]
• Support System
• Stressors/Stress Management Practices

Pathophysiological Discussion:

[In this section, cite one scholarly article using APA format and discuss the current disease process, the etiology of the patient's illness, and potential complications that may occur with treatments and the patient's overall prognosis.]

Medications:

[Provide a table with details of medications, including classification, dose, route, frequency, purpose/mechanism of action, and significant side effects/adverse reactions, along with nursing implications.]

Nursing Process Section:

Nursing Diagnosis:

Priority Nursing Diagnosis Related to As Evidence By Rationale (reason for priority)
1
2
3
4

Table for Nursing Diagnosis Number 1

Assessment

• Signs and symptoms relative to the nursing diagnosis, as evidence by:
o 2 objective
o 2 subjective

Patient Outcome

Interventions/Implementations

Evaluation

• SMART
o Specific
o Measurable
o Attainable
o Realistic
o Timely

Table for Nursing Diagnosis Number 2

Assessment

• Signs and symptoms relative to the nursing diagnosis, as evidence by:
o 2 objective
o 2 subjective

Patient Outcome

Interventions/Implementations

Evaluation

• SMART
o Specific
o Measurable
o Attainable
o Realistic
o Timely

References: