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Relearning: Clinical Judgment Plan of Care Template
Student Name: CJSim™ Client Initials: Age/DOB: Allergies: BSA/BMI: Code Status: | Date of Admission: Date of Care: Admitting Diagnosis: Comorbidities: Planned Treatments/Procedures: |
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider orders | |
Cultural/Spiritual: Neurological/Cognition/Coping/Adaptation/Function: Nutrition/Elimination: Fluid/Electrolytes/Acid-Base: Gas Exchange/Perfusion: Glucose Regulation: | Health Promotion/Development: Infection/Immunity/Inflammation: Mobility: Pain/Comfort/Tissue Integrity: Safety: Other: |
START of Shift (CJSim™) Priorities | |||
Recognize & Analyze Cues | Prioritize Hypotheses | Generate Solutions & Take Actions | Evaluate Outcomes |
Priority Assessments/Cues | Priority Hypotheses for Nursing Care | Priority Interventions/Actions | Priority Teaching/Discharge Needs |
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Priority Laboratory Tests/ Diagnostic Cues | Priority Actual & Potential Complications/Cues | Priority Medications | Priority Collaborative Actions |
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Vital Signs & Pertinent Lab Trends | |
START of the Shift (CJSim™) Analysis (phase 1) | END of the Shift (CJSim™) Analysis (phase 3) |
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CJSim™ Purposeful Clinical Judgment | Clinical Debriefing |
Answer these questions about today's client:
| Answer these questions about today's client:
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END of Shift (CJSim™) Priorities — How Has Your Client Changed? | |||
Recognize & Analyze Cues | Prioritize Hypotheses | Generate Solutions & Take Actions | Evaluate Outcomes |
Priority Assessments/Cues | Priority Hypotheses for Nursing Care | Priority Interventions/Actions | Priority Teaching/Discharge Needs |
| | | |
Priority Laboratory Tests/ Diagnostic Cues | Priority Actual & Potential Complications/Cues | Priority Medications | Priority Collaborative Actions |
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CONSIDER QUESTIONS Document the Answers to Your Questions Here | ||
Consider Questions from CJSim™ Question #1 | Consider Questions from CJSim™ Question #2 | Consider Questions from CJSim™ Question #3 |
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Nurse Think® CJSimTM Reflection Exercise
Assignment: After providing care during the CJSim™ and completing the plan of care template for your assigned client, answer the following reflection questions focusing on the care you provided for this CJSim™ client.
CJSim™ Reflection Questions:
What additional information would you need to provide more comprehensive care for the client?
What could you have done better or differently to improve the outcome? Why?
Describe what was most challenging for you when caring for the client(s).
Identify the additional equipment, resources, or assistance needed to improve the care you provided.
Share the key areas of care that were new to you that you had not experienced before.
How will your above reflections impact your future practice and improve your clinical judgment?
Reference
NurseTim, Inc. (2021). NurseThink® clinical judgment plan for care template for CJSim RN.
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