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Cedar Crest College Medical Diagnosis Information of Patients Worksheet

Cedar Crest College Medical Diagnosis Information of Patients Worksheet

Question Description

Do not take the question IF YOUR MAJOR IS NOT A NURSE

JUST NURSES. I need you to fully complete the SBAR form and to know how to best do the SBAR.

SBAR is a tool used for documentation and organization of the client in the clinical setting. Fill out the SBAR form addressing each area:

    1. S: Situation
    2. B: Background
    3. A: Assessment
    4. R: Recommendations
    5. Medications
    6. Plan of Care/Concept Maps
    7. Psychosocial Assessment
    8. Clinical Reflection Questions

Other useful resources that will be helpful in filling out the SBAR tool properly include: SMART goals (specific, measurable, attainable, realistic, and timely) from NUR110 class. Additional resources to aide in writing proper SMART goals/Plan of care are located in the Pearson book 3rd edition Volume I page 632. The basic 12-minute head-to-toe assessments learned in NUR210 class to comprehensively address the head to toe assessment with descriptions of normals and abnormals of assessment findings in the client. ATI medication templates need to be filled out for all medications (scheduled and prn).

Please ensure to review the SBAR grading rubric for details on how this assignment is calculated.

Process:

A minimum of two (2) SBARs will be completed to satisfactory level for each of the eight criteria. A clinical instructor will require the SBAR to be re-submitted until a total score of eight is achieved for each SBAR. A clinical instructor may require additional SBAR completion up to a total of four (4) if a student is not obtaining satisfactory scores. A student may fail clinical if SBARs are not satisfactory level by the end of the clinical rotation. The SBAR can be found in canvas. The clinical instructor will individually determine the SBAR due dates for each student in the clinical setting.

Rubric

SBAR Rubric (2)

SBAR Rubric (2)

Criteria Ratings Pts

This criterion is linked to a Learning OutcomeS: Situation

1 pts

Satisfactory

All information is complete.

0 pts

Unsatisfactory

Information is incomplete.

1 pts

This criterion is linked to a Learning OutcomeB: Background

1 pts

Satisfactory

All information is complete with evidence of understanding of the patient’s background.

0 pts

Unsatisfactory

Information is incomplete and/or does not provide evidence of understanding of the patient’s background.

1 pts

This criterion is linked to a Learning OutcomeA: Assessment

1 pts

Satisfactory

All information is complete with evidence of understanding of the patient’s assessment data and the implications.

0 pts

Unsatisfactory

Information is incomplete and/or does not provide evidence of understanding of the patient’s assessment data implications.

1 pts

This criterion is linked to a Learning OutcomeR: Recommendations

1 pts

Satisfactory

All information is complete with identification of appropriate recommendations for the patient care.

0 pts

Unsatisfactory

Information is incomplete regarding identification of appropriate recommendations for the patient care.

1 pts

This criterion is linked to a Learning OutcomeMedications

1 pts

Satisfactory

All required information is present and patient specific.

0 pts

Unsatisfactory

Information is incomplete.

1 pts

This criterion is linked to a Learning OutcomePlan of Care/Concept Maps

1 pts

Satisfactory

Plan of care is specific to the actual patient care priorities.

0 pts

Unsatisfactory

Plan of care is not specific to the actual patient care priorities.

1 pts

This criterion is linked to a Learning OutcomePsychosocial Assessment

1 pts

Satisfactory

Information is complete and patient specific.

0 pts

Unsatisfactory

Information is incomplete or not patient specific.

1 pts

This criterion is linked to a Learning OutcomeClinical Reflection Questions

1 pts

Satisfactory

All information is complete and student has demonstrated meaningful reflection for improving practice.

0 pts

Unsatisfactory

Information is incomplete and/or student has not demonstrated meaningful reflection for improving practice.

1 pts

Total Points: 8


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