My patient is a four-year-old female whose diagnosis is a brain tumor in her pineal region, Everything else can be made up but has to correlate with her diagnosis. Please look at the template. It has to hit all the requirements of the rubric.
A Turnitin plagiarism receipt is also needed.
Thank youClinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
Student Name
Clinical Judgement Plan
Professor Name
Date
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
)
Medical History: (SEE RUBRIC REQUIREMENTS
)
PAST DIAGNOSED MEDICAL PROBLEMS
For each disease identified, define, it, describe pathophysiology, and cite source
Surgical History: (SEE RUBRIC REQUIREMENTS
)
PAST DIAGNOSED SURGICAL PROBLEMS
For each procedure identified, define & describe it; include year of procedure & cite source
Social History:
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE
ALCOHOL/ ELICIT DRUG USE
Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns: include the following Social Determinants of Health (SDOH) (SEE RUBRIC REQUIREMENTS
)
❋Economic Stability
❋ Education
❋Social and Community Context
❋ Health and Health Care
❋ Neighborhood and Built Environment
Erickson’s Developmental Stage Related to pt. & Cite References (1) *
List and Discuss specific stage (based on objective assessment)
(SEE RUBRIC REQUIREMENTS
)
TIME OUT!!! Student instructions:
Pathophysiology of Primary Medical Dx (reason for hospitalization) Support with Evidence Based Citations
Pathophysiology of Primary Medical Dx (reason for
Ex: The primary pathophysiologic process in COPD is persistent but variable inflammation of the airways
(SEE RUBRIC REQUIREMENTS
)
hospitalization)
TIME OUT!!! Student instructions:
(SEE RUBRIC REQUIREMENTS
)
Patient Education (In Pt.) for Referrals/ Discharge Planning
REFERRALS NEEDED/CASE Management
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
Medical Management and Collaborative Plan
(From MD, PT, OT notes…. etc.) *Consider past 24 – 48 hours
(SEE RUBRIC REQUIREMENTS
)
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE
EQUIPMENT11/14/22, 8:09 PM Clinical Judgment Plan
https://canvas.westcoastuniversity.edu/courses/23793/assignments/578656 2/9
Criteria Ratings Pts
4 pts
8 pts
4 pts
Assessment & History of
Present Illness
Recognizing cues focused
on observation
4 pts
Proficient
HPI explains in
detail with
accurate and in-
depth
understanding of
chief complaint
and supported by
evidence-based
citations.
3.04 pts
Acceptable
HPI explains in
some detail with
moderate
understanding
of chief
complaint or no
support from
evidence-based
citations.
2.4 pts
Needs
Improvement
HPI explains in
limited detail
with insufficient
understanding of
chief complaint
or support from
evidence-based
citations.
0 pts
Unsatisfactory
HPI details
limited with
poor
understanding
of chief
complaint and
no evidence-
based citations
to support.
Recognizing assessment
parameters
Clinical thinking and
assessment cues
8 pts
Proficient
Identifies the 4
imperative
assessment
cues and or
medical
diagnoses
supported by
evidence-
based
citations.
6.08 pts
Acceptable
Identifies 2
imperative
assessment
cues and or
medical
diagnosis
supported by
evidence-
based
citations.
4.8 pts
Needs
Improvement
Identifies 1
imperative
assessment
cues and or
medical
diagnosis,
vaguely
supported by
evidence-based
citation.
0 pts
Unsatisfactory
Unable to identify
any imperative
assessments
parameters relevant
to medical
diagnosis and
without supported
evidence-based
citation.
Interpreting diagnostic
criteria & diagnostic tests
and procedures
Clinical reasoning and
analysis of cues
4 pts
Proficient
Clearly and
accurately
describes the
client’s
diagnostic
criteria which
clearly supports
the chief
complaints and
presenting
signs/symptoms.
3.04 pts
Acceptable
Adequately
describes the
client’s
diagnostic
criteria which
adequately
supports the
identified chief
complaint and
presenting
signs/symptoms
2.4 pts
Needs
Improvement
Vaguely
describes the
client’s
diagnostic
criteria which
vaguely
supports the
identified chief
complaint and
presenting
signs/symptoms.
0 pts
Unsatisfactory
Lack
description of
the client’s
diagnostic
criteria that
does not
support the
identified chief
complaint and
presenting
signs/symptoms
11/14/22, 8:09 PM Clinical Judgment Plan
https://canvas.westcoastuniversity.edu/courses/23793/assignments/578656 3/9
Criteria Ratings Pts
8 pts
8 pts
Past medical & surgical
history, pathophysiology
Clinical judgment and
recognizing cues
8 pts
Proficient
Past
medical/surgical
history detailed
with full
explanation of
pathophysiology
for admitting
diagnosis and for
each diagnosis &
accurate detail
with specific
detail related to
the client’s
history and
symptoms and
supported by
evidence-based
citations.
6.08 pts
Acceptable
Past
medical/surgical
history given
with partial
explanation of
identified
admitting
diagnosis and
preexisting
medical
diagnoses,
intermittent
details related to
the client’s
history and
symptoms, or
not completely
supported by
evidence-based
citations.
4.
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