Choose one patient at clinical to complete a concept map. Paraphrase the patient’s history and physical data ensuring inclusion of the following information to create patient introduction data for the concept map:
History of Present Illness (HPI)
Age: In decades e.g 65 years should be 60s
Gender
Code status
Allergies
Isolation and precaution
VS on admission and date of care. Include POX and pain
Admitting diagnosis
Activity/Functional level
Bowel & Urinary elimination status
Skin integrity
Morse and Braden score
DVT prophylaxis
Labs: Na, K, a, C02, BUN, Creat, glucose, WBC, H/H, Platelet, PT, PTT, and INR
***Provide a minimum of 2 assessment data to support your top 3 prioritized problems
**** Look at the healthcare provider’s assessment and plan under H & P or progress note and patient care orders for assessment and interventions data.
*** If any of the above requested data is not available in your patient’s record, indicate unavailability Note posted concept map care plan guidelines and grading rubric.
The post Clinical Patient Clinical Judgement Concept Map first appeared on Writeden.
