School of Health Professions, Science and Wellness

Department of Nursing

Daily Clinical log

Spring 2017

Course: __________________________________________________________________________

Student: _________________________________ Date: _____________________________

Client’s Initials: ___________ Age: _________ Sex: ________ Room#: ________________

Date of Admission: ________________ Date of Care: _____________________________

Present Medical Diagnoses: ____________________________________________________

Present Surgery (if applicable): _____________________Date of Surgery: ______________

Allergies: __________________________ Code Status: ________________________

Vital Signs T_____________ P_____________ R____________ BP______________ SPO₂___________

General Appearance

Psychiatric

HEENT

Neck

Breasts

Lymph Nodes

Pulmonary

Cardiovascular

Skin

Nails

Abdomen

Genitourinary

Pelvic

Rectal

Extremities

Musculoskeletal

Neurological (DTR’s, reflex grading, cranial nerve evaluation)

Incisions

Drains

Diet/Nutrition

IVs

Intake and Output

Fall Risk Assessment (include score)

Pressure Ulcer Risk Assessment (include score)

Pain assessment (include reassessment)

Time	Score	Intervention	Reassessment Time	Score

Diagnostic Assessments – Important EKGs, X-Rays, and Labs

Lab/Other Test	Patient values	Inference

Medications Administered:

Medications Dose/Brand name/Generic name	Indication of use	Adverse Effect/Side effect	Nursing Implications

Treatments and Procedures	Day & Times	Rationale

Nursing Interventions:

Assessment Findings	Nursing Diagnosis	Outcome	Nursing Interventions	Evaluations

Reflections of the day on meeting course objectives: