cjp 1

Clinical Judgement Plan

Instructor:

DATE Care Provided and UNIT:

Student Name

Clinical Judgement Plan

West Coast University

Professor Name

Date

Social History

Patient Information

Patient Initials:

Admission Date:

Age & Gender:

Admission Weight:

Allergies:

Code Status:

Legal status:

Living Will/ DPOA:

History of Present Psychiatric Illness (HPI)

Psychiatric Diagnosis and DSM 5 Diagnostic Criterion

Psychiatric Admitting Psychopathology

Medical History & Pathophysiology

Erikson’s Developmental Stage Related to Patient (1) *List and discuss specific stage (based on objective assessment)

Social Determinants of Health

Ethnicity

Occupation

Religion

Family support

Insurance

3 Psychosocial Considerations/Concerns

Substance Abuse and Other Addictions

Type:

Amount / Frequency:

Duration:

Last Used:

Withdrawal Symptoms:

Type:

Amount / Frequency:

Duration:

Last Used:

Withdrawal Symptoms:

Involuntary Movements

Code: 0 = None 1 = Minimal 2 = Mild 3 = Moderate 4 = Severe

I: Facial and Oral Movements: (movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling,

grimacing, puckering, pouting, smacking, biting, clenching, chewing, mouth opening , lateral movement , tongue darting in and out of mouth)

Code:

II: Extremity Movements:

Upper (arms, wrists, hands, fingers) Include choreic movements (i.e. rapid objectively purposeless, irregular, spontaneous athetoid movements.)

Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot

Code:

III: Trunk Movements: (Rocking, twisting, squirming, pelvic gyrations)

Code:

IV: Global Judgment: (Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal movements.)

Code:

V: Dental Status: (Current problems with teeth and/or dentures/Endentia?)

Yes/No

C.A.G.E. Questionnaire

Have you ever felt you should cut down on your drinking?

Yes / No

Have people annoyed you by criticizing your drinking?

Yes / No

Have you ever felt bad or guilty about your drinking?

Yes / No

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?

Yes / No

Teaching Assessment and Client Education

Discharge Planning

Risk Assessment

Lab Tests with Values

(Include normal ranges, dates, and rationales of abnormal results)

Lab Tests or Diagnostic Tests	Normal Ranges	Admission Lab Values	Current Lab Values	Explain Abnormal Results R/T Your Patient (USE additional pages at the end of template WHEN NEEDED)

Diagnostics

(3) Relevant Diagnostic Procedures with Results

(2) Medications

Medication Name

Include Generic name, Trade name, and Medication Class.

Include OTC, herbal (non-pharmacological items) and PRN medications given during clinical

Dose

Route

Frequency

Purpose of Medication for Your Patient

Mechanism of Action

Side Effects/

Adverse Reactions

Nursing Considerations Specific to Your Patient/Teaching

Physical Assessment/Review of Systems

Vital Signs/Height/Weight (4)

Temp:

HR:

BP:

RR:

SpO2:

Pain:

Height:

Weight:

Level of Participation in Program/Activity

Gait and Motor Coordination

Presenting Appearance

Behavioral Approach

Speech

Interpersonal Characteristic and Approach to Evaluation

Recall and Memory/Orientation

Judgement and Insight

Hallucinations and Delusions

Rapport and Expressions

Response to Failure/Impulsivity/ Anxiety

Mood and Affect

Concentration and Attention

Alertness/Coherence

Thought Process

Responding

Observation

Interpreting

Implement

Planning

Analysis

Assessment

Take Action

Generate Solutions

Prioritize Hypotheses

Analyze Cues

Recognize Cues

Evaluate

Evaluation

1.

2.

3.

4.

Reference Page