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NURS 304 CLINICAL DOCUMENTS 1
Sistema Universitario Ana G. Méndez, Inc.
School of Health Sciences
Department of Nursing
Continental USA Branch Campuses
Universidad del Turabo
Documento Clínico
Clinical Documents
NURS 304
© Ana G. Méndez University System, Inc. 2018
All rights reserved.
NURS 304 CLINICAL DOCUMENTS 2
TABLA DE CONTENIDO/TABLE OF CONTENTS
PÁGINA/PAGE
INFORMACIÓN GENERAL DEL CURSO .................................................................................. 3
GENERAL COURSE INFORMATION ......................................................................................... 5
WORKSHOP TWO ......................................................................................................................... 8
TALLER TRES ............................................................................................................................... 9
WORKSHOP FOUR ..................................................................................................................... 11
TALLER CINCO ........................................................................................................................... 12
WORKSHOP SIX ......................................................................................................................... 13
TALLER SIETE ............................................................................................................................ 15
CLINICAL EVALUATION TOOLS ............................................................................................ 16
NURS 304 CLINICAL DOCUMENTS 3
I. INFORMACIÓN GENERAL DEL CURSO
A. Objetivos Clínicos
Al finalizar el curso, el estudiante será capaz de:
1. Aplicar el proceso de enfermería interviniendo con mujeres y recién nacidos.
2. Evaluar el rol profesional en la atención al paciente desde la preconcepción.
3. Aplicar las habilidades de pensamiento crítico y el juicio clínico en la toma de decisiones
mediante intervenir con mujeres y recién nacidos.
4. Use los principios éticos y legales para ser considerado en la toma de decisiones en
llevando a cabo sus intervenciones de enfermería.
5. Demostrar habilidades de liderazgo al proporcionar cuidados de enfermería a mujeres y
recién nacidos.
6. Aplicar habilidades de resolución de problemas integrando el equipo de salud.
7. Use los estándares de práctica para guiar la atención centrada en la mujer y el recién nacido.
8. Demuestra competencia en habilidades de enfermería y uso de tecnología para brindar
atención a mujeres y recién nacidos.
NURS 304 CLINICAL DOCUMENTS 4
F. Evaluación
El componente clínico del curso, será evaluado basado en una calificación de “PASS” o “Fail”.
Es un requisito pasar el componente clínico del curso.
PRÁCTICA CLÍNICA
CRITERIOS DE EVALUACIÓN
CRITERIOS DESCRIPCIÓN ESPECÍFICA TALLER(ES)
Examen de cálculo
de dosis
Los estudiantes presentarán la prueba durante el primer día del
curso clínico. La prueba debe aprobarse con un mínimo de 80 %
para poder continuar con el componente clínico.
Nota: Tendrás dos intentos: el primer intento en la semana 1
y un segundo intento en la semana 7 del curso clínico. De no
aprobar el mismo, el estudiante no podrá practicar en el área
clínica y fracasará el componente de laboratorio.
1 y 7 P
Pruebas cortas Pruebas cortas semanales para evaluar habilidades clínicas. 2-6 P
Prueba de práctica
de habilidades
durante el taller
Demostración final de habilidades seleccionada al azar. 7 P
Actividades previas
relacionadas a los
trabajos asignados
para atender
clientes
Planes de cuidado
Estudios de caso
Plan de enseñanza
Plan nutricional
Evaluación de Competencia Cultural
Recursos: Clinical Essentials, libro de texto del curso
2 - 15 P
Práctica clínica
diaria y simulación
durante la práctica
clínica
Estudios de caso
Simulación de la ejecución
Plan de cuidado de enfermería
(SBAR) Informe
Transferencia del paciente
Documentación del paciente
Recursos: Clinical Essentials
8 - 15 P
Rendimiento
clínico durante el
taller
Evaluación del rendimiento del alumno durante la práctica
clínica. Se basa en el instrumento Clinical Evaluation Tool for
Midterm and Final.
11 Midterm
12.5%
15 Final 12.5%
P
Calificación Pass/Fail
NURS 304 CLINICAL DOCUMENTS 5
I. GENERAL COURSE INFORMATION
A. Clinical Objectives
Upon completing this course, the student will be able to
1. Apply the nursing process by intervening with women and newborns.
2. Evaluate the professional role in patient care from preconception.
3. Apply critical thinking skills and clinical judgment in decision-making by
intervening with women and newborn.
4. Use the ethical and legal principles to be considered in decision-making in
carrying out their nursing interventions.
5. Demonstrate leadership skills by providing nursing care to women and newborns.
6. Apply problem solving skills integrating health team.
7. Use the standards of practice to guide the women-centered care and newborn.
8. Demonstrates competency in nursing skills and use of technology to provide care
to women and newborns.
NURS 304 CLINICAL DOCUMENTS 6
B. Evaluation
The clinical component of the course will be evaluated on a Pass or Fail basis. It is required to
pass the clinical component in order to pass the course.
EVALUATION TABLE
CLINICAL PRACTICE
CRITERIA SPECIFIC
DESCRIPTION
WORKSH
OP (S)
WEIGHT
Dosage calculation
exam
The students present the test during the first day of the
clinical course. The test must be passed with a minimum
of 80 % in order to continue to the clinical component.
Note: You will have two attempts to take the test.
First attempt on week one and second attempt on
workshop seven.
* If the student fails to achieve an 80% on the test, he
will not be able to proceed with the clinical practice
and will fail the Clinical Component of the course.
1 & 7 P
Quizzes Weekly skills quizzes. 20% 2-6 P
Skills Practice Test
During Workshop
Final demonstration of randomly selected skill. 20% 7 P
Patient Workload
Assignments
Before Workshop
Care Plans
Case Studies
Teaching Plan
Nutritional Plan
Cultural Competency Assessment
Resourses: Clinical Essentials, Course Textbook 20%
2 - 15 P
Daily Clinical Practice
and Simulation
During Workshop
Case Studies
Simulation Execution
Nursing Care Plan
(SBAR) Report
Patient Transfer
Patient Documentation
Resourses: Clinical Essentials 20%
8-15 P
Clinical Performance
During Workshop
Evaluation of the student performance during clinical
practice. Is based in the instrument Clinical Evaluation Tool
for Midterm and Final 20%
11 Midterm
12.5%
P
15 Final
12.5%
Total Pass/ Fail %
NURS 304 CLINICAL DOCUMENTS 7
TALLER UNO
Durante la práctica en el laboratorio de destrezas, se espera que:
1. El facilitador discuta los siguientes temas:
a. Examen físico e histórico del sistema reproductivo femenino
b. Examen de senos
c. Examen vaginal
d. Métodos contraceptivos
e. Regla de Naegele para estimar la fecha probable de parto
f. Signos y síntomas del embarazo.
g. Gravidez y paridad (GTPAL) & (GP) [5 digits; 2 digits]
h. Adaptaciones fisiológicas durante el embarazo
i. Necesidades nutricionales durante el embarazo
j. Evaluación prenatal
2. Los estudiantes tomen apuntes y participen realizando preguntas para aclarar dudas que
puedan tener.
3. Los estudiantes reciban la orientación del laboratorio de simulación que incluirá el
componente discusión post-conferencia.
4. Actividad de Simulación: Observación y manejo del simulador obstétrico.
A. Referencias específicas del taller
Lowdermilk, D.L., Perry, S.E., Cashion, K. & Alden, K.R. (2016). Maternity and
Women’s Healthcare. (11th ed). Wt. Louis, MO: Elsevier, Inc.
NURS 304 CLINICAL DOCUMENTS 8
WORKSHOP TWO
After the completion of the Laboratory and Simulation Skill, the students will be able to:
1. Understand and discuss the following topics:
a. Leopold maneuver
b. Fetal heart rate / Electronic Fetal Monitoring (EFM)
c. Non-stress test (NST)
d. Oxytocin stress test
e. Antepartum care and assessment
2. Will practice all the discussed activities in the High Definition Clinical Simulators.
Simulation Skills for the scenarios
A. Simulation Scenario #1
1) Prepare and conduct an assessment using breast and
Papanicolaou test (60 min).
A. Specific Workshop References
Lowdermilk, D.L., Perry, S.E., Cashion, K. & Alden, K.R. (2016). Maternity and Women’s
Healthcare. (11th ed). Wt. Louis, MO: Elsevier, Inc.
Khan Academy Medicine. (2015, March 19). Diabetes in pregnancy: Reproductive system
physiology NCLEX-RN [Video file]. Retrieved from
https://www.youtube.com/watch?v=N3jnRuzseoM&feature=youtu.be
NURS 304 CLINICAL DOCUMENTS 9
TALLER TRES
Luego de finalizado el laboratorio de destrezas, se espera que los estudiantes:
1. Discutan con el facilitador los siguientes temas o destrezas:
a. Cuidados intraparto y parto
b. Cuidado perianal
c. Laboratorios
d. Asistir con amniotomía
e. Inserción de Foley catéter
f. Evaluación de cambios de la frecuencia fetal
g. Educación al paciente
h. Documentación la historia medica
Durante la discusión, los estudiantes tomarán apuntes y realizarán preguntas para aclarar
dudas que puedan tener.
2. Estén preparados para realizar las destrezas de simulación:
a. Edad gestacional
b. Preparación para una cesárea
c. Evolución fetal
d. Educación al paciente
e. Documentación en la historia médica
3. Realicen el siguiente escenario de Simulación:
a. Escenario #2 Examen de non-estrés (60 minutos)
A. Referencias específicas del taller
Boral, B. M, Williams, D., & Boral, L. I. (2016). Disseminated intravascular coagulation
from. American Journal of Clinical Pathology, 146 (6), 670-680. Recuperado de
NURS 304 CLINICAL DOCUMENTS 10
https://academic.oup.com/ajcp/article/146/6/670/2703125/Disseminated-Intravascular-
Coagulation
Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2013). Maternal child nursing
care. (5ta ed.). Atlanta, GA: Elsevier.
Sinaí, M. (2013, febrero 7). Hiperemesis gravídica [Archivo de video]. Recuperado de
https://www.youtube.com/watch?v=MU-y5L6qIJE&feature=youtu.be
NURS 304 CLINICAL DOCUMENTS 11
WORKSHOP FOUR
The facilitator will discuss the following nursing skills (competencies):
a. Newborn nursing care
b. Neonate physical assessment
c. Apgar score, weight and body measurements and vital signs
d. Cord blood collection for banking or Rh-
e. Pharmaceuticals and immunizations
f. Medical record documentation
g. Client education (breastfeeding)
2. Simulation skills for the scenarios:
a. Skills that will be completed on week four for scenario #4:
i. Delivery preparation for normal vaginal birth
ii. Care of neonate
iii. Pharmacological and non-pharmacological pain management
3. Simulation scenario:
a. Scenario #3- Admission and preparation of patient for cesarean section (60
minutes).
G. Specific Workshop References
Lowdermilk, D.L., Perry, S.E., Cashion, K. & Alden, K.R. (2016). Maternity and Women’s
Healthcare. (11th ed). Wt. Louis, MO: Elsevier, Inc.
Khan Academy Medicine. (2015, March 19). Labor- Reproductive system physiology NCLEX-
RN [Video file]. Retrieved from https://youtu.be/Bf04LcSBpDw
NURS 304 CLINICAL DOCUMENTS 12
TALLER CINCO
El facilitador discutirá las siguientes destrezas de enfermería:
a. Evaluación del fondo uterino post parto vaginal o cesárea
b. Evaluación de sangrado y perineo
c. Evaluación de los cambios en la loquia
d. Cuidado post episiotomía o laceración
e. Administración de Rogan
f. Educación al paciente
g. Documentación de la historia médica
Durante la discusión, los estudiantes tomarán apuntes y realizarán preguntas para
aclarar dudas que puedan tener.
1. Destrezas de simulación:
a. Cuidado de perineo inmediato (hemorragia)
b. Signos vitales y evaluación del flujo vaginal
c. Manejo farmacológico y no farmacológico del dolor
2. Escenario de simulación:
a. Escenario #5 Hemorragia post-parto (60 minutos)
A. Referencias específicas del taller
Lowdermilk, D.L., Perry, S.E., Cashion, K. & Alden, K.R. (2016). Maternity and
Women’s Healthcare. (11th ed). Wt. Louis, MO: Elsevier, Inc.
NURS 304 CLINICAL DOCUMENTS 13
WORKSHOP SIX
The facilitator will discuss the following nursing skills and competencies:
a. Newborn identification and foot prints
b. Apgar score
c. Suctioning with bulb and nasogastric tube
d. Thermoregulation and temperature
e. Weight and length measurements
f. Erythromycin ointment application
g. Vitamin K administration
h. Hepatitis B vaccine administration (if required)
i. Umbilical cord care
2. Simulation skills for the scenarios (Skills will be completed on week six for scenario #6):
a. Comprehensive newborn assessment
b. Vital signs assessment
c. Weight and length measurements
d. Suctioning with bulb and nasogastric tube
e. Umbilical cord care
f. Medication administration
g. Medical Record documentation
3. Simulation scenario #5:
a. Post-partum hemorrhage (60 minutes)
NURS 304 CLINICAL DOCUMENTS 14
Specific Workshop References
Ascott0222. (2014, November 10). Chapter 15 fetal assessment during labor [Video file].
Retrieved from https://www.youtube.com/watch?v=1BGXxRK-tFM&feature=youtu.be
Lowdermilk, D.L., Perry, S.E., Cashion, K. & Alden, K.R. (2016). Maternity and Women’s
Healthcare. (11th ed). Wt. Louis, MO: Elsevier, Inc.
NURS 304 CLINICAL DOCUMENTS 15
TALLER SIETE
El facilitador discutirá las siguientes destrezas de enfermería:
a. Evaluación de paciente con pre-eclampsia
b. Monitoreo de los signos y síntomas de complicaciones de pre-eclampsia
c. Manejo de la Pre-eclampsia
d. Evaluación de los reflejos profundos y clonos
e. Evaluación fetal
Durante la discusión, los estudiantes tomarán apuntes y realizarán preguntas para aclarar dudas que
puedan tener.
1. Se ofrecerá un examen práctico e individual acerca de todas las destrezas que los alumnos
han estudiado y repasado durante las primeras seis semanas del curso (instrucción
práctica). El examen se calificará como “aprobado o desaprobado” y se considerará como
requisito para continuar participando en la parte clínica de la clase.
A. Referencias específicas del taller
Lowdermilk, D.L., Perry, S.E., Cashion, K. & Alden, K.R. (2016). Maternity and Women’s
Healthcare. (11th ed). Wt. Louis, MO: Elsevier, Inc
NURS 304 CLINICAL DOCUMENTS 17
Guide to the Nursing Process
This guide will be of help to your organization in the preparation of the Nursing Process. You should start
preparing it as soon as you select your client. If in doubt, consult your teacher.
1. Presentation page - See APA.
2. Table of Contents - See APA.
3. Introduction - Give the reader a general idea of the content of the work.
4. Customer Profile - It is a spoken portrait of your client. You must include customer identification data such
as: age, sex, religion, marital status, medical diagnoses, days of hospitalization, reason for hospitalization, signs
and symptoms that the client presented at the time of admission and when you intervened with him or her ,
medicines he/she uses and special treatments..
5. Data Analysis - You must use a table format (see table I attached). Remember to cite the source used when
doing the analysis. The analysis is to compare the data obtained from the client with the data of the literature and
to establish the relationship between the two.
6. Laboratory and studies performed - Includes laboratories significant to the condition of the client with their
results. It will include the description of the laboratory or study, the values obtained by the client, the normal
values and the relationship of these results with the condition of the client. See Table II.
7. Medications - Include the medications the client is currently using. Includes complete medical order (name,
dose, route, frequency), indication, side effects, nursing responsibility and relation to the client. See Table III.
8. List of problems or needs (current and potential), strengths (resources) and limitations (weaknesses) - You
must organize it in order of priority. It includes everything that helps or supports the client to satisfy or solve
their needs or problems, as well as what prevents or limits. See Table IV.
9. Care Plan - Use the format given in class. The diagnosis of nursing must be separated from the analysis of
previous data and the identification of problems or needs. Select the highest priority nursing diagnoses (current,
potential and health promotion) and submit it with the PES system. Prepare the plan of care for nursing
diagnoses. Remember to write the objective (s) correctly using the five elements: subject, verb, situation
(condition), adequacy (criteria) and time (see the notes of the Class and textbook). Care plans will be delivered
using Docu Care
10. Conclusion of the work - Includes a summary of the content of the work and its
usefulness for professional development.
11. References - These must be updated (last 5 years), written according to APA and there must
be at least 5 references. All references cited in the Data analysis should be included in the
list of references.
12. Appendix - Health history and physical examination will be delivered using Docu Care. The
appendices contain any other material used to provide a client care. Example:
Information materials, whether brochures, Pamphlets, information taken from the Internet. |
Remember to quote the appendices and identify them correctly. The last part of the appendix
are the Evaluation Criteria.
*Check the work before submitting it (wording, sequence, spelling, etc.).
Also use the criteria to verify that the work includes all parts which will be evaluated. Hand in the
work at the time that stipulates the norms of Course. Below is a model of the tables that should be
included.
NURS 304 CLINICAL DOCUMENTS 18
I. Table for Presentation and Analysis of Data
Data Analysis
Client Information
Some data to analyze:
Examples:
A) Age (use theorists
like: Erick Erickson).
B) Gender
C) Place of Residence
D) Civil Status
E) Academic level
F) Religion
G) Occupation
H) Previous hospitalizations
I) Medical Diagnosis
Current
J) Significant findings
of physical examination
Perform an assessment of Needs according to Maslow
Theories and sources of reliable information should
be apply in data analysis.
Literature review data are compared with client data.
II. Table of Laboratories
Name and
Description
Results client's Values Normal Values Relationship with
Client’s Condition
Example: "Complete
Blood Count "
(CBC) - Explain the
Components of the
Lab and the
importance.
Ex: Hemoglobin
(HGB) = 13.5 g / dl
Write the rank of
Values expected.
Ex: Men:
12.4-14.9 g /DL Women:
11.7 to 13.8 g /
DL
Explain the relationship of
the results with the
Current condition of the
patient
III. Table of Medications
Name, Dose,
Via and
Frequency
Indication Secondary Effects Nursing
Responsibility
Relationship
with the
Client
Tylenol 500mg
PO Every 6 hours
Explain how to use
and for what is use
Write the
Adverse effects
reactions
Common and the
more
Dangerous for
Each system.
Which are the
Aspects / care
that the nursing
personal should
take into account
to administer this
medicine?
What
purpose is use
in the client?
(take in account
the health history.
and
current status)
NURS 304 CLINICAL DOCUMENTS 19
IV. Table Problems of the Client
EXAMPLE
OF WHAT TO INCLUDE IN THE CARE PLAN
Problems Resources Limitations
Must be arrange in priority.
The student must place all
Problems identified in a list
that is divided into current and
potential
Aspects that
support the client to
solve his/her needs.
Aspects that prevent or
limit the client.
Nursing Diagnosis Client’s Objectives Nursing
Interventions
Rationale Evaluation
P - Problem
E - Etiology
S - Signs and
Symptoms that show
the
existence of the
problem
Format of
Potential Problem:
P - Problem
E - Etiology
Each objective
Should:
1. Be directed
to the patient.
2. Have a verb
(Measurable).
3. Present one
situation.
4. Have
Adequacy.
5. Have a period of
time to achieve the
objective
Include what the
Nursing Professional
will do to
direct the client to
achieve the
objectives.
Classify
independent /
Collaborative
Explain the reason
and importance
of each
intervention
It must be grounded
and
justified the
explanation of
each nursing
intervention
Indicate to what
extent the objectives
were achieved
through
each nursing
intervention.
There must be a
explanation of how
the evaluation
was done for each
objective.
NURS 304 CLINICAL DOCUMENTS 20
Evaluation Criteria for the Nursing Process
Name___________________________ Date___________________
Professor___________________________ Points/ Grade_____________
Criteria 4 3 2 1 0 N/A Comments
I. Competent Practice
A. Make a nursing assessment
1. Writes a complete patient profile.
2. Writes: nursing history, physical
examination, and data relevant to the patient's
current condition in the electronic record.
3. Describes the significant findings of the
patient's nursing history and physical
examination correctly and relates them to the
current problem.
II. Critical Thinking
A.Interprets significant data from the nursing
assessment related to the current situation or
problem
1. Analyze laboratory results and / or
studies.
2. Analyze medications used by the patient.
3. Analyze the pathophysiology of the medical
diagnoses
4. Analyzes the stage of growth and
development according to Eric Erikson and the
impact of health condition.
5. Apply Abraham Maslow's theory of needs
satisfaction to the patient's current situation to
Identify and explain affected needs
6. Identify current and potential list of nursing
problems by considering the patient as a
holistic being.
7. Writes nursing problems in priority order.
8. Describe patient's strengths and limitations
to work with the health situation or problem.
III. Clinical Judgment
A. Design a nursing care plan for the nursing
diagnoses and
Solution of the patient's highest priority
problems.
NURS 304 CLINICAL DOCUMENTS 21
1. The identified diagnoses contain the
necessary elements (problem, etiology, signs
and symptoms).
a. Performs a minimum of three nursing
diagnoses; one diagnosis focused on a current
problem, another diagnosis related to a risk
(potential problem) and one in health
promotion. You must present justification for
not having each type of diagnosis indicated.
2. Writes observable objective behavior
(includes 5 components of objectives).
3. Write nursing interventions for the
identified diagnosis (classified in independent
and collaborative).
4. Describe the scientific rationale for
designed nursing actions
5. Establish the aspects to be considered as
nursing professionals in the evaluation of the
objective (s).
6. Writes a conclusion with a reflection on the
client's situation, the role of the nursing
professional in his care and his/her learning as
a student.
IV. Research Skills
A. Evidences the search and use of relevant
and scientific literature when relating
information from the literature with findings
found in the assessment
V. Presentation of Paper
A. The use of the APA format is evidenced.
B. Has a clear introduction.
C. Makes use of grammar rules.
D. Has clear and coherent ideas.
E. The references used in the preparation of
the work:
1. Diversity of professional sources
2. Complete and correct
3. Last 5 years.
NURS 304 CLINICAL DOCUMENTS 22
Scale:
4 - Has complete mastery of the knowledge and / or skills required all the time
3 - Has mastery of the knowledge and / or skills required most of the time.
2 - Has mastery of knowledge and / or skills required sometimes.
1 - Has mastery of the knowledge and / or skills rarely required.
0 - No evidence of any knowledge or skills in its execution.
NURS 304 CLINICAL DOCUMENTS 23
Evaluation Criteria Leadership Role Competencies
Name: _________________________________ Date ____________________________
Professor: ________________________________ Grade: ______ % ______
*During the clinical practice of this course the student is expected to achieve the competences with minimum
or no teacher help.
Criteria 4 3 2 1 0 N/A Comments
I. COMPETENT PRACTICE
A. Communication Skills (15%)
1. Shows therapeutic communication skills with:
a. Patient
b. Family
c. Professor
d. Peers
e. Interdisciplinary Health team
2. Demonstrates appropriate communication:
a. Tone
b. None verbal language
c. Professional vocabulary
d. Follows communication channels
3. Written Communication with minimal or no help from the teacher.
a. Task assignment
b. Weekly work plan
c. Writes modifications to the nursing plan
d. Evaluates own implementation of the plan
B. Cultural and ethical sensitivity (5%)
1. Respets cultural preferences, values, beliefs and behaviors of the patient,
family, peers and interprofessional team
2. Demonstrates an ethical behavior in the care and management of
patients in their professional role by respecting values (Respect for
Human Dignity, Responsibility, Commitment, Honesty, Integrity,
Loyalty, Justice, Equity, Authenticity
C. Leadership (60%)
1. Supervision
a. Arrives early (1 hour before)
b. Notify teacher in time when unable to assist the clinical
c. Wears full and clean uniform with identifications.
d. Brings complete equipment to the clinical setting
e. Report to teacher when task begins or ends
f. Oversees team members to carry out their tasks
g. Demonstrates Leadership Qualities
a. Demonstrates initiative in the execution of task
NURS 304 CLINICAL DOCUMENTS 24
Criteria 4 3 2 1 0 N/A Comments
b. Keeps control of emotions
c. Handles unexpected events
according to the qualities of a leader.
h. Deliver data relevant to continuity of care to the leader of the next
shift.
i. Provides complete and organized documentation to the teacher
(Portfolio-1 week after completing his / her leader role)
2. Work Assignment
a. Carries out the essential elements of planning, organization, direction
and evaluation of the team in charge
a. Verify patient census
b. Verify the work program of the unit's staff
c. Evaluates the level of staff preparation when assigning the task
d. Establish the categorization of patients according to individual needs
e. Assign other tasks related to patient care
f. Assigns tasks related to patient safety and care environment
g. Assign tasks related to quality improvement
h. Distributes tasks evenly
1.Provides specific oral instructions on allocation
2. It takes into consideration the location of
patients
3. Is available to answer question that may arise
4. Assigns lunch time and break
i. Includes infection control management in assignment of tasks
3. Team / patient education
a. Estimate the educational need
b. Plan ahead
c. Write the objectives, content, educational strategies and the evaluation
plan
1. Promotes educational activity
d. Discuss the subject and content with the teacher prior to the activity
e. Facilitates assistance to team members
f. Has mastery of content
g. Stimulates audience participation
h. Answer related questions of the topic
i. Evaluates the educational activity
D. Management of information systems (5%)
1. Complies with the regulations and rules of the HIPAA Act)
2. Complies with the regulations of the Institution
E. Patient Care Technologies
1. Demonstrates knowledge and skills in the use of technologies for patient
care (technological equipment for patient care)
NURS 304 CLINICAL DOCUMENTS 25
II. CRITICAL THINKING
A. Autoevaluación Objetiva (10%)
1. Engages in an objective self-evaluation process considering their beliefs
and values and how they relate to their practice as a leader.
2. Entrega reflexión final que refleje su desarrollo profesional al profesor
1. Intervenes using critical judgment according to institutional standards
2. Promotes the defense of patient's rights
III. RESEARCH SKILLS
A. Uses relevant literature (5%)
1. Uses reliable and relevant scientific literature to apply it in its role as
leader
2. Demonstrates skills in finding, evaluating, and synthesizing evidence to
improve care outcomes with minimal assistance and support
3. Integrates non-traditional alternatives for the solution and improvement of
situations involving patients or interprofessional team
Professor’s Signature: _______________________ Student’s Signature:
_________________________
Date: ______________________
Scale:
4 - Has complete mastery of the knowledge and / or skills required all the time
3 - Has mastery of the knowledge and / or skills required most of the time.
2 - Sometimes has mastery of knowledge and / or skills required.
1 - Rarely has mastery of the knowledge and / or skills required.
0 - No evidence of any knowledge or skills in its execution.
Critical judgment and decision making
NURS 304 CLINICAL DOCUMENTS 30
Evaluation Criteria for Documentation in the Electronic Record
Name___________________________ Date___________________
Professor___________________________ Points/ Grade_____________
Scale:
Yes (1 point) - The criterion is fully completed and as indicated.
No (0 point) - Does not take into account the criterion.
N / A- Criterion does not apply
Criteria Yes No N/A Comments
1.Competent Practice
A. Nursing Documentation
1.Writes relevant data that reflects the current
condition (nursing assessment) of the patient
2. Evidence of nursing interventions
according to identified problems
3. Evidence of the patient's response to the
nursing interventions offered.
4. Entries in the electronic record are complete
5. The information is presented in logical order
(nursing note).
6. Nursing notes follow grammatical rules
(consistent in syntax, spelling).
7. Deliver on time the documentation made.
NURS 304 CLINICAL DOCUMENTS 31
Bachelor Degree of Science Nursing
Clinical Teaching Plan
Student Name: ____________________________Date: _________________ Time:
____________
Client Initials: ____________________________ Sex: __________________
Age: _____________
Behavioral Objectives/Goals:
__________________________________________________________________________________
____________________________________________________________________
Readiness to Learn:
__________________________________________________________________________________
__________________________________________________________________________________
_____________________________________________________________
Barriers to Learning:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________
NURS 304 CLINICAL DOCUMENTS 32
Nursing Teaching Plan of Care
Assessment
Nursing
Diagnosis
Nursing Intervention/
Implementation
Scientific
Rationale
Evaluation Date Modification
Subjective
Data:
Objective
Data:
NURS 304 CLINICAL DOCUMENTS 33
Evaluation Criteria for Education Plan
Name___________________________ Date___________________
Professor___________________________ Points/ Grade_____________
Criteria 4 3 2 1 0 N/A Comments
Critical Thinking
I. Planning
A. Select topic according to needs of
the patient
B. Coordinates the activity with
members of the health team.
C. Prepares the physical and
psychological environment to
facilitate learning.
D. Discuss the detailed outline with
the teacher one week in advance
(subject, plan, visual and
demonstrative material).
II. Content:
A. Selects the content relevant to the
topic.
B. Writes objectives in terms of
observable behavior
C. The content is in accordance with
the objectives formulated.
D. Presents the content in a logical
sequence.
III. Method - Strategies:
A. Selects the strategies that most
facilitate the
presentation of the content and shows
creativity.
B. The method is selected according
to the number and characteristics of
the clients for whom the activity is
planned.
Professional Competence
C. Implements the selected strategy.
NURS 304 CLINICAL DOCUMENTS 34
IV. Development of the Plan:
A. Faces the clients
B. Gets the attention of the clients.
C. Speaks clearly and slowly.
D. Discusses planned educational
material.
E. Uses a simple language in tune
with the learner's educational level.
F. Pays attention and listen to the
group's reactions as he/she speak.
G. Clarifies the scientific terms used
in the presentation
H. Offers opportunity for
participation.
I. Uses quality audiovisual material
(clear and of adequate size).
J. Remains within the allotted time
limit.
K. Clarifies other situations brought
by clients
L. Creates quality written material
that meets the established objectives.
M. Demonstrates mastery of content.
N. Closes the topic by mentioning
the most important points.
V. Evaluation:
A. Performs assessment of learning
at the end of the educational activity.
B. Carries out the evaluation
according to the objectives outlined.
C. At the end of the activity, leaves
the area used in order.
VI. Written and oral presentation: A. Follows the rules for submitting
papers
according to APA style.
B. Completes the teaching plan
format.
C. Follows grammatical rules.
D. Expressed correctly.
NURS 304 CLINICAL DOCUMENTS 35
E. References.
1. Recent dates (last 5 years).
2. Correct and complete
Research Skills
Evidences the search and use of
diverse, relevant and scientific
literature when preparing the
content of the educational activity
(minimum 3 sources).
Scale:
4 - The criteria are complete.
3 - The criteria almost complete.
2- The criteria partially complete.
1- The criteria are not complete
N / A - Does not apply.