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cjp 1

complete the attached file

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

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