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CJP

Clinical Judgement Plan

Instructor:

DATE Care Provided and UNIT:

Student Name

Clinical Judgement Plan

West Coast University

Professor Name

Date


OB History

GTPAL:


Prenatal Panel

Blood Type/Rh:
GBS:
Hep B:
HIV:
Rubella:
RPR:
Chlamydia:
Gonorrhea:
HSV:


Delivery Summary

Gestational age:

Delivery Type:

Delivery Time:

Postpartum Day:
Placenta Delivery Time:
Lacerations/Episiotomy:
QBL:
APGAR Score:

ROM type and time:

Complications:


Social History


Patient Information

Patient Initials:

Admission Date:

Chief Complaint:

Age & Gender:

Admission Weight:

Allergies:

Code Status:

Living Will/ DPOA:


History of Present Illness (HPI)


Admitting Diagnosis & Pathophysiology


Medical History & Pathophysiology


Surgical 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


Teaching Assessment and Client Education





Discharge Planning


Interprofessional Consults and Multidisciplinary Plan





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

Postpartum BUBBLE Assessment

Time of care: ____________________________________



Labor Assessment


Episiotomy/Laceration/


Incision


Vital Signs/Height/Weight

Temp:

HR:

BP:

RR:

SpO2:

Pain:

Height:

Weight:


Bowel


Bladder



Uterus


Breasts


Respiratory


Cardiovascular


Neurological


Emotional


DVT


Lochia

Time of care: ____________________________________


HEENT


Psychosocial


Hydration/Nutrition


Vital Signs/Height/Weight

Temp:

HR:

BP:

RR:

SpO2:

Pain:

Height:

Weight:


Genitourinary (GU)


Vaginal Exam/Leopold’s


Lines/Drains/Tubes


Gastrointestinal (GI)


Safety


Respiratory


Cardiovascular


Neurological


Musculoskeletal and Activity


Integumentary


Endocrine



Responding

Observation

Interpreting

Implement

Planning

Analysis

Assessment


Take Action


Generate Solutions


Prioritize Hypotheses


Analyze Cues


Recognize Cues

Evaluate


Evaluation

Reference Page

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