Relearning: Clinical Judgment Plan of Care Template Student Name: Client Initials: Age/DOB: Allergies: BSA/BMI:

Student Name:

Client Initials:

Age/DOB:

Allergies:

BSA/BMI: Code Status:

Date of Admission:

Date of Care:

Admitting Diagnosis:

Comorbidities:

Planned Treatments/Procedures:

Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider orders

Cultural/Spiritual:

Neurological/Cognition/Coping/Adaptation/Function:

Nutrition/Elimination:

Fluid/Electrolytes/Acid-Base:

Gas Exchange/Perfusion:

Glucose Regulation:

Health Promotion/Development:

Infection/Immunity/Inflammation:

Mobility:

Pain/Comfort/Tissue Integrity:

Safety:

Other:

START of Shift (CJSim™) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to phase 1/Question 1 section)

Recognize & Analyze Cues

Prioritize Hypotheses

Generate Solutions & Take Actions

Evaluate Outcomes

Priority Assessments/Cues

Priority Hypotheses for Nursing Care

Priority Interventions/Actions

Priority Teaching/Discharge Needs

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2.

3.

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3.

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Priority Laboratory Tests/ Diagnostic Cues

Priority Actual & Potential Complications/Cues

Priority Medications

Priority Collaborative Actions

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Vital Signs & Pertinent Lab Trends

START of the Shift (CJSim™) Analysis (phase 1/Question 1 section)

END of the Shift (CJSim™) Analysis (phase 3/Question 3 section)

(CJSim™) Mid-Shift Purposeful Clinical Judgment (Complete after reviewing EHR/Question 2 section)

Clinical Debriefing (Complete these questions after completely caring for the client and answering the questions for the client)

Answer these questions about today’s client:

1.
Recognize Cues —
Explain any assessment changes since the start of shift.

2.
Analyze Cues —
How are the changes important or significant?

3.
Prioritize Hypothesis —
What could be causing the changes?

4.
Generate Solutions —
What can/should you do about these changes?

5.
Take Action —
What did I do about it? What would I do about it?

6.
Evaluate Outcomes —
Did my actions make a difference? Why are why not? What should have been done differently?

Answer these questions about today’s client:

1.
Compare this client with one that you’ve cared for previously in clinical, simulation, or a class case study. What things were the same and what was different related to their condition, assessment findings, provider prescriptions, medications, etc?

2.
Compare this client with the “textbook” , what was the same and what was different?

END of Shift (CJSim™) Priorities — How Has Your Client Changed? (phase 3/Question 3 section)

Recognize & Analyze Cues

Prioritize Hypotheses

Generate Solutions & Take Actions

Evaluate Outcomes

Priority Assessments/Cues

Priority Hypotheses for Nursing Care

Priority Interventions/Actions

Priority Teaching/Discharge Needs

1.

2.

3.

1.

2.

3.

1.

2.

3.

1.

2.

3.

Priority Laboratory Tests/ Diagnostic Cues

Priority Actual & Potential Complications/Cues

Priority Medications

Priority Collaborative Actions

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2.

3.

4.

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6.

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2.

3.

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2.

3.

CONSIDER QUESTIONS Document the Answers to Your Questions Here

Consider Questions from CJSim™
Question #1

Consider Questions from CJSim™
Question #2

Consider Questions from CJSim™
Question #3

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