Clinical Orientation -Fall 2025 by Donna Goelz

dgoelz1 — 2025-03-04 17:17:38 UTC

What do you hope to get out of this experience?

Report

dgoelz1 — 2025-03-04 17:17:38 UTC

PPE Demonstration

dgoelz1 — 2025-03-04 17:17:40 UTC

Interactive demonstration of proper PPE donning and doffing sequence. Students will practice in pairs and use Padlet to document their observations.

EPIC Charting and Progress Notes

dgoelz1 — 2025-03-04 17:17:46 UTC

Chart:

Adult Patient Care Summary
Pain
I&O's - REAL TIME
Vital Signs - REAL TIME
Daily Cares - REAL TIME
- Bath
- ADL's
- Turning
- Brushing of teeth
- Toileting

Policy Review

dgoelz1 — 2025-03-04 17:17:50 UTC

Find and review P&P -before doing common procedures such as:

NG & G-tube meds
Chest tubes
Foleys / Straight cath
Use your skills rubrics
- IV push medications

SBAR

dgoelz1 — 2025-03-04 17:26:44 UTC

You will provide a SBAR report on your patient(s) to the group daily.

PAIN - documentation

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Progress notes

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You will write a progress note for your patient(s) prior to leaving.

PIE format

Patient statement - what is their chief complaint
Interventions - what did you do
Evaluation - were your interventions effective?
- Important to document things such as:
  - How did your patient ambulate - with or without assistance, gait steady, etc.
  - Examples ...

Post Conference

dgoelz1 — 2025-03-04 18:58:16 UTC

Discussion

Review - Clinical Expectations

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Sick - call in procedure
Breaks
Off-unit experiences

Clinical Expectations

dgoelz1 — 2025-03-04 19:02:14 UTC

Documentation: You are expected to chart a complete assessment on each of your patients every day, and verify with
instructor and all required shift charting/documentation must be completed no later than 2 hours prior to the
end time of the clinical day, unless otherwise discussed and approved by your instructor.

You must complete ALL documentation prior to leaving for the
day on clinical days

Please note that back-charting is visible in Epic (i.e. if you chart at
120 that you assessed your patient at 0930, we can see that you entered this information at 1230, which would be
considered late).

Verify with your instructor what may/may not be charted in Epic versus on a separate assessment
document, which is specific to your clinical site.

Care of Feeding Tubes

dgoelz1 — 2025-03-04 22:50:42 UTC

Caring for NGMJTubes

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Providing Post Care

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Wound Vac

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Prior to leaving for the shift

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Report to both RN and CNA
Charting is completed and signed off by instructor
Progress notes
Rooms -cleaned up

Chest Tubes

dgoelz1 — 2025-03-08 20:17:47 UTC

Standard of Care

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Things to know!

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Vital signs are to be taken between 15-1600 AND again between 19-2000
Pain assessment is to be documented every shift
- Reassessment of pharmacological or non-pharmacological interventions need to be documented within 30 minutes for IV and 1 hour for PO or NON-pharmacological - never to exceed 1 1/2 hours
- Tidy rooms -empty garbage and linen bags
- Record I&O's
- Hourly rounds on your patients
- Turn patients every 2 hours & check for incontinence
- Stock gloves!
- WORK AS A TEAM

Introductions

dgoelz1 — 2025-09-22 14:03:30 UTC