The Essentials of Clinical Documentation: Preparing Students for Clinical Success

This clinical manual is an ideal and standardized platform for preparing nursing students with the essential tools for documenting their nursing process. It teaches nursing students how to gather important data about each client in the clinical setting.

Using this manual, the student nurse will be able to perform high quality documentation that is accurate and consistent in the client profile and laboratory and diagnostics, and their correlation and significance to the client’s diagnosis or diagnoses. This manual also covers the medication administration record, nursing interventions and rationales, and intake and output forms. The Situation Background Assessment Recommendation (SBAR) form and the use of a concept map complete the list of resources provided. 
Using this standardized documentation, the student will be able to:
• Identify the primary patient data (past and present), diagnosis, and treatment plan.
• Analyze patient data correlating and drawing conclusions relevant to patient outcome.
• Document finding in a systematic manner.
• Interpret diagnostic findings as relate to patient diagnosis
This manual is intended for use in medical, surgical, and critical care clinical nursing courses.