Relearning: Clinical Judgment Plan of Care Template
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 |
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 |
1. 2. 3. | 1. 2. 3. | 1. 2. 3. | 1. 2. 3. |
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. 2. 3. 4. 5. 6. | Answer these questions about today’s client: 1. 2. |
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 |
1. 2. 3. | 4. 5. 6. | 1. 2. 3. | 1. 2. 3. |
CONSIDER QUESTIONS Document the Answers to Your Questions Here | ||
Consider Questions from CJSim™ |
Consider Questions from CJSim™ |
Consider Questions from CJSim™ |
1. 2. 3. | 1. 2. 3. | 1. 2. 3. |
Nurse Think® CJSimTM Reflection Exercise
Assignment: After providing care during the CJSim™ and completing the plan of care template for your assigned client, answer the following reflection questions focusing on the care you provided for this CJSim™ client.
CJSim™ Reflection Questions:
· What additional information would you need to provide more comprehensive care for the client?
· What could you have done better or differently to improve the outcome? Why?
· Describe what was most challenging for you when caring for the clients in the CJSim™?
· Identify the additional equipment, resources, or assistance needed to improve the care you provided.
· Share the key areas of care that were new to you that you had not experienced before.
· How will your above reflections impact your future practice and improve your clinical judgment?
NurseTim, Inc. (2021). NurseThink® clinical judgment plan for care template for CJSim RN.
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© 2023 Chamberlain University. All Rights Reserved. Relearning Clinical Judgment Plan of Care Template-Sept2023 v1.1