Nursing care summation/reflection/progress note
Nursing Care Summation
Nursing care is dependent upon caregivers? assessment, prioritization of care needs, and evaluation of patient and family responses. Growth into a new role is enhanced by reflection.
Please select one patient from your patient assignment in collaboration with your clinical instructor between clinical weeks 3 and 7. This patient must have multiple acute and chronic health conditions. The summation is to be completed following your clinical experience with the patient. Complete the following:
1. A brief overview of the patient?s reason(s) for hospitalization, treatments received/scheduled, and progress to date.
2. Narrative head to toe (or by systems) assessment.
a. You may use the facility?s documentation system as a guide. The narrative physical assessment history may follow the template outlined in the health assessment textbook – ?normal? or ?within normal limits? are not to be used as descriptors.
3. Select a minimum of 3 priority NANDA approved diagnoses for your patient. Remember to think priority!
4. Focused progress note of your clinical shift with the patient
a. Document your plan of care, interventions performed, and patient/family responses noted during your clinical shift with the patient in the form of a narrative progress note. Accurate documentation of time is vital in a medical record. The progress note should include accurate times (written in military time). Remember, the progress note should (at minimum) address the 3 priority nursing diagnoses.
5. Reflection of the clinical day
a. Describe your clinical performance for the day. Include positive experiences and areas for growth. Discuss the interactions encountered or observed on the unit (ancillary staff, nursing staff, physician/nurse practitioner/physician assistant staff, family members). Discuss strategies for change. The reflection should be about one page in length (typed, double-spaced).
Section Expected Criteria Points Awarded/Points Possible
Overview of Pt. Hospitalization Accurately and concisely provides brief overview of the patient?s reason(s) for hospitalization, treatments received/scheduled, and progress to date.
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Narrative Assessment Accurately provides a thorough narrative of physical assessment findings. Does not use ?WNL? or normal as descriptors.
Nursing Diagnoses Appropriately identifies 3 priority NANDA approved diagnoses for patient (5 points for each)
Progress Note Appropriately and accurately documents care provided and patient/family responses noted during the clinical experience. Addresses 3 priority diagnoses.
Personal Reflection Critically reflects on personal performance during clinical day. Identifies interactions among health care team.
Grammar/Spelling/Punctuation Correct grammar, spelling, and punctuation are an expectation in higher education. /10