Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
Yaneisy Yanez
Clinical Judgement Plan
West Coast University
Professor Viego
08/01/2024
Patient Information
(1)
Patient Initials:
Age & Gender: Age in years/not DOB
Height/Weight:
Code Status:
Living Will/ DPOA:
Chief Complaint
Ex: SUBJECTIVE (Abnormal – Bullet Points)
What is the cause of the patients problem now describing i.e., Pt is having SOB 8/10 with exertion?
Admitting Diagnosis & Admission Date
History of Present Illness (HPI)
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY GOT TO THE HOSPITAL- UNTIL NOW WHEN YOU ARE PROVIDING CARE? (USE SEPARATE ATTACHED WORD DOC WHEN NEEDED) (SEE RUBRIC REQUIREMENTS )
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