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 (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
