Nursing Clinical Log

0 comments

Example. Please fill out the table attached. These is an example of how is must be completed. This is for a class in adult health, you can choose presenting problem that you think of.

Date

Client Age

Presenting Problem

Clinical Experience

Level of Student Participation

9/30/2020

Middle adult: 40s to 60s

“I am homeless and am hearing things and they scare me”

Z00.01 Encounter for general adult medical examination with abnormal findings; R94.31 Abnormal electrocardiogram [ECG] [EKG]; I15.0 Renovascular hypertension; E08.5 Diabetes mellitus due to underlying condition with circulatory complications; R44.0 Auditory hallucinations

Shared (<50%)

9/30/2020

Young-old: 60s to 74 years

“I am seeing double everyday”

Z00.0 Encounter for general adult medical examination; H54.51 Low vision, right eye, normal vision left eye; H53.2 Diplopia

Primary (>50%)

9/30/2020

Young-old: 60s to 74 years

“I have been feeling strange and feel like my heart races at times”

Z00.01 Encounter for general adult medical examination with abnormal findings; R94.31 Abnormal electrocardiogram [ECG] [EKG]; I48.4 Atypical atrial flutter

Primary (>50%)

About the Author

Follow me


{"email":"Email address invalid","url":"Website address invalid","required":"Required field missing"}