So, any nursing student can understand how frustrating going through clinical paperwork and creating care plans, nursing diagnoses, and “related too” and “as evidence by” are. Basically, I’d like to set my NANDA list on fire, but none the less I cannot because it is quite important in school.
There is relief though! Well actually not really. I don’t have any magical care plan powers, and to be completely honest I find them frustrating and I am not amazing at them (maybe B level, but not A’s). Anyways, I have found that if you have all the information from the day compiled neatly and organized, then its usually easier to compile the data and turn it into appropriate Nursing Diagnoses.
Now, I’ve seen tons of my peers clipboards and notebooks after a long day on the unit (even though we only get one or two patients, nursing students are a rare breed that can make notes on the tiniest things) and what I’ve seen is a confusing whirlwind of information. So I have devised a sheet that I use during clinicals that help me compile my information. Now, this is what my school really focuses on, so therefore it is not going to be tailored to any one program. I’ve created it using just a simple word document.
You can view and download it by clicking here: Clinical Paperwork
So, one thing I cannot do is include what I would normally write underneath the “Significant Labs” section, which for me would be to draw a fishbone lab diagram like this one pictured below, to help illustrate the lab values.
So, what I’ve created is just an easy way to compile your information from a long day at clincals and to help process and formulate nursing diagnoses through your assessments. Hope if anyone decides to download and use it that it helps!