KINGDOM OF SAUDI ARABIA المملكة العربية السعودية
Ministry of Higher Education وزارة التعليم العال
University of Hail
College of Nursing جامـعـة حـائل
كلية التمريض
CLINICAL LOG
Student Name
University Number
Instructor Name
Health Assessment
A. Demographic Data
Patient Name Ward
Age Marital Status Room
Gender Occupation Bed Number
B. Health Characteristics
Height(cm) Date of Admission
Weight(kg) Surgical Intervention
Body Mass Index Date of Surgery
Medical Diagnosis:
Definition
Causes
C. Hemodynamic Baseline
Temperature Blood Pressure
Pulse Rate Mean Arterial Pressure(MAP
Respiratory Rate Central Venous Pressure(CVP)
SPO2 Others:
D. Reason for Admission (Chief Complaint)
KINGDOM OF SAUDI ARABIA المملكة العربية السعودية
Ministry of Higher Education وزارة التعليم العال
University of Hail
College of Nursing جامـعـة حـائل
كلية التمريض
CLINICAL LOG
E. Past Medical or Surgical History
F. Physical Examination
Technique Findings
Inspection
Percussion
Palpation
Auscultation
G. Current Medications
Date Name of Drug Route, Dosage Classification Indication Side Effects Nursing
,Frequency Considerations
KINGDOM OF SAUDI ARABIA المملكة العربية السعودية
Ministry of Higher Education وزارة التعليم العال
University of Hail
College of Nursing جامـعـة حـائل
كلية التمريض
CLINICAL LOG
DRUG COMPUTATION
KINGDOM OF SAUDI ARABIA المملكة العربية السعودية
Ministry of Higher Education وزارة التعليم العال
University of Hail
College of Nursing جامـعـة حـائل
كلية التمريض
CLINICAL LOG
H. Laboratory Results & Diagnostic Procedures
Date Test Results Normal Value Interpretation Nursing
Considerations
H.1 DIAGNOSTIC/ IMAGING TEST
Date Test Results/ Interpretation Nursing Considerations
I. Intake and Output
Time Intake Output Others
Oral/N IV NGT BT Urine NGT Drainage
TOTAL
BALANCE
KINGDOM OF SAUDI ARABIA المملكة العربية السعودية
Ministry of Higher Education وزارة التعليم العال
University of Hail
College of Nursing جامـعـة حـائل
كلية التمريض
CLINICAL LOG
IV computation:
J. Health Teachings
K. Documentation
Teacher’s
Date/ Time FOCUS Nurse’s Notes
Remarks
Signature:
Title:
KINGDOM OF SAUDI ARABIA المملكة العربية السعودية
Ministry of Higher Education وزارة التعليم العالي
University of Ha’il جامـعـة حـائل كلية
College of Nursing التمريض
L. Nursing Process
Assessment/Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation
(Prioritize)
Subjective Data:
Objective Data:
5 Page
____________________________________________________
For Evaluators 3 Ideal The student's answer exceeds expectations. All information needed based on patient-specific health needs are provided.
only 2 Acceptable The student satisfactorily provided the information needed based on patient-specific health needs. The student answer/
entry is partially correct/ lacking or incomplete.
1 Poor The student did not provide an answer. Incorrect answer/ entry.
No. Items for Evaluation Score
1 A. DEMOGRAPHIC DATA
2 B. HEALTH CHARACTERISITICS
3 C. HEMODYNAMIC BALANCE
D. REASON FOR ADMISSION (CHIEF
4
COMPLAINT)
5 E. PAST MEDICAL OR SURGICAL HISTORY
6 F. PHYSICAL EXAMINATION
7 G. CURRENT MEDICATION
8 G.1 COMPUTATION
H. LABORATORY RESULTS AND DIAGNOSTIC
9
PROCEDURES
10 I. INTAKE AND OUTPUT
11 I.1 COMPUTATION
12 J. HEALTH TEACHING
13 K. DOCUMENTATION
14 L Nursing Process
RAW SCORE/ TOTAL # OF ITEMS x 15 =
Checked by:
____________________________________________
Field Teaching Staff Name and Signature / Date
6 Page
