Clinical Prep Tool
CLINICAL PREPARATION TOOL
Purposes: • To provide an organized method of client data collection. • To provide a format for researching client data. • To provide a standard format for reporting client data. • To serve as a format for developing and evaluating a plan of care for the client.
Guidelines:
1. This tool is to be completed as per clinical instructor’s requirements. 2. Completion is required to demonstrate clinical preparedness. You may be dismissed from clinical if this tool is not completed. 3. This tool is to be considered under HIPPA Policy; therefore, confidentiality precautions are required. Initials should be used, information should be kept in a secure location and not available for general viewing. To discard – shred or black out any client identifiers such as diagnosis, initials, room number, age, and date of admission. 4. General instructions for completion of the tool will be given during the orientation period of each clinical rotation. 5. This tool may be completed by generating the format on computer, typing, or legibly handwritten (if allowed by your clinical instructor), using black ink. Place name bottom right of each page to prevent lost loose pages. 6. There are 3 components of the tool – Assessment, Planning, Implementing/Evaluating. 7. Directions regarding dates that the tool is be completed for submission to the instructor for grading will be announced and/or identified by course instructor. 8. When the tool is submitted for grading, place the completed tool in a 9 x 12 brown envelope. Place your name, the course name, your section number, and the clinical instructor’s name in the upper left hand corner. The envelope may be used multiple times during the semester. 9. The Clinical Preparation Tool will be graded as “satisfactory” or “unsatisfactory.” 10. Please reference work using APA format.
Part 1 – Assessment
The History- Subjective
Purposes: • To provide an organized method of client data collection. • To provide a format for researching client data. • To provide a standard format for reporting client data. • To serve as a format for developing and evaluating a plan of care for the client.
Guidelines:
1. This tool is to be completed as per clinical instructor’s requirements. 2. Completion is required to demonstrate clinical preparedness. You may be dismissed from clinical if this tool is not completed. 3. This tool is to be considered under HIPPA Policy; therefore, confidentiality precautions are required. Initials should be used, information should be kept in a secure location and not available for general viewing. To discard – shred or black out any client identifiers such as diagnosis, initials, room number, age, and date of admission. 4. General instructions for completion of the tool will be given during the orientation period of each clinical rotation. 5. This tool may be completed by generating the format on computer, typing, or legibly handwritten (if allowed by your clinical instructor), using black ink. Place name bottom right of each page to prevent lost loose pages. 6. There are 3 components of the tool – Assessment, Planning, Implementing/Evaluating. 7. Directions regarding dates that the tool is be completed for submission to the instructor for grading will be announced and/or identified by course instructor. 8. When the tool is submitted for grading, place the completed tool in a 9 x 12 brown envelope. Place your name, the course name, your section number, and the clinical instructor’s name in the upper left hand corner. The envelope may be used multiple times during the semester. 9. The Clinical Preparation Tool will be graded as “satisfactory” or “unsatisfactory.” 10. Please reference work using APA format.
Part 1 – Assessment
The History- Subjective