Fundamental: | Nursing

Clinical Requirement:

templatecareplan.pdf Relearning: Clinical Judgment Plan of Care Template Relearning Clinical Judgment Plan of Care Template-July24 © 2024 Chamberlain University. All Rights Reserved. 1 Student Name: Client Initials: Age/DOB: Allergies: BSA/BMI: Code Status: Date of Admission: Date of Care: Admitting Diagnosis: Comorbidities: Planned Treatments/Procedures: Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider orders Cultural/Spiritual: Neurological/Cognition/Coping/Adaptation/Function: Nutrition/Elimination: Fluid/Electrolytes/Acid-Base: Gas Exchange/Perfusion: Glucose Regulation: Health Promotion/Development: Infection/Immunity/Inflammation: Mobility: Pain/Comfort/Tissue Integrity: Safety: Other: START of Shift (CJSim™) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to phase 1/Question 1 section) Recognize & Analyze Cues Prioritize Hypotheses Generate Solutions & Take Actions Evaluate Outcomes Priority Assessments/Cues Priority Hypotheses for Nursing Care Priority Interventions/Actions Priority Teaching/Discharge Needs 1. 2. 3. 1. 2. 3. 1. 2. 3. 1. 2. 3. Priority Laboratory Tests/ Diagnostic Cues Priority Actual & Potential Complications/Cues Priority Medications Priority Collaborative Actions 1. 2. 3. 1. 2. 3. 1. 2. 3. 1. 2. 3. Relearning: Clinical Judgment Plan of Care Template Relearning Clinical Judgment Plan of Care Template-July24 © 2024 Chamberlain University. All Rights Reserved. 2 Vital Signs & Pertinent Lab Trends START of the Shift (CJSim™) Analysis (phase 1/Question 1 section) END of the Shift (CJSim™) Analysis (phase 3/Question 3 section) (CJSim™) MID-SHIFT Purposeful Clinical Judgment (Complete after reviewing EHR/Question 2 section) Answer these questions about today's client: 1. Recognize Cues — Explain any assessment changes since the start of shift. 2. Analyze Cues — How are the changes important or significant? 3. Prioritize Hypothesis — What could be causing the changes? 4. Generate Solutions — What can/should you do about these changes? 5. Take Action — What did I do about it? What would I do about it? 6. Evaluate Outcomes — Did my actions make a difference? Why are why not? What should have been done differently? END of Shift (CJSim™) Priorities — How Has Your Client Changed? (phase 3/Question 3 section) Recognize & Analyze Cues Prioritize Hypotheses Generate Solutions & Take Actions Evaluate Outcomes Priority Assessments/Cues Priority Hypotheses for Nursing Care Priority Interventions/Actions Priority Teaching/Discharge Needs 1. 2. 3. 1. 2. 3. 1. 2. 3. 1. 2. 3. Priority Laboratory Tests/ Diagnostic Cues Priority Actual & Potential Complications/Cues Priority Medications Priority Collaborative Actions 1. 2. 3. 1. 2. 3. 1. 2. 3. 1. 2. 3. Clinical Debriefing (Complete these questions after completely caring for the client and answering the questions for the client) Answer these questions about today's client: 1. Compare this client with one that you've cared for previously in clinical, simulation, or a class case study. What things were the same and what was different related to their condition, assessment findings, provider prescriptions, medications, etc .? 2. Compare this client with the "textbook", what was the same and what was different? Relearning: Clinical Judgment Plan of Care Template Relearning Clinical Judgment Plan of Care Template-July24 © 2024 Chamberlain University. All Rights Reserved. 3 CONSIDER QUESTIONS Document the Answers to Your Questions Here Consider Questions from CJSim™ Question #1 Consider Questions from CJSim™ Question #2 Consider Questions from CJSim™ Question #3 1. 2. 3. 1. 2. 3. 1. 2. 3. Reflection Exercise (After providing care during the CJSim™ and completing the plan of care template for your assigned client, answer the following reflection questions focusing on the care you provided for this CJSim™ client.) CJSim™ Reflection Questions: 1. What additional information would you need to provide more comprehensive care for the client? 2. What could you have done better or differently to improve the outcome? Why? 3. Describe what was most challenging for you when caring for the clients in the CJSim™? 4. Identify the additional equipment, resources, or assistance needed to improve the care you provided. 5. Share the key areas of care that were new to you that you had not experienced before. 6. How will your above reflections impact your future practice and improve your clinical judgment? NurseTim, Inc. (2021). NurseThink® clinical judgment plan for care template for CJSim RN . CJSIMBenchmarkfundamental.pdf Student Overview CLARIS NJIKE ID: D41284211 CourseFundamentals: Patient Care- Belcher Instructor Elissa Belcher AssessmentW7 NR226 CJE Fundamentals Benchmark 2551 Assessment Date 10/13/2025 MY SCORE 67.23% CLASS AVERAGE 68.69% NATIONAL AVERAGE 65.37% StdDev 0.0857 Mean 34.3444 Median 34.4583 Rank 5 / 6 Class Percentile 0.25 National Percentile0.5635 Category Performance Student Score National Average Average Score Range Needs Improvement Needs Review Doing Well NurseThink Testing 119 items Category Name Student Score National Average Class Average Points Status CJE Exam Version 67.23% 65.37% 68.69% 33.616667 CJE Benchmark 67.23% 65.37% 68.69% 33.616667 Clinical Judgment Measurement Model 67.23% 65.37% 68.69% 33.616667 1-Recognize Cues 78.57% 69.71% 75.79% 5.5 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 1/15 Category Name Student Score National Average Class Average Points Status 2-Analyze Cues 58.5% 56.4% 59.42% 5.85 3-Prioritize Hypotheses 73.81% 70.69% 77.38% 5.166667 4-Generate Solutions 71.43% 64.46% 64.76% 5 5-Take Actions 77.78% 70.53% 71.3% 7 6-Evaluate Outcomes 51% 63.55% 67.31% 5.1 Concept 67.23% 65.37% 68.69% 33.616667 Accountability Concept 53.33% 45.55% 71.11% 1.6 Advocacy Concept 100% 40.16% 16.67% 1 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 2/15 Category Name Student Score National Average Class Average Points Status Clotting Concept 100% 83.61% 83.33% 1 Comfort Concept 68.75% 73.55% 71.18% 2.75 Communication Concept 56.25% 63.58% 75% 2.25 Culture Concept 50% 68.34% 75% 1 Ethics Concept 100% 91.75% 86.11% 3 Fluid & Electrolyte Balance Concept 86.67% 78.21% 85.56% 2.6 Functional Ability Concept 45.83% 61.51% 60.42% 0.916667 Health Promotion Concept 50% 70.08% 58.33% 0.5 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 3/15 Category Name Student Score National Average Class Average Points Status Infection Concept 100% 57.4% 100% 2 Intracranial Regulation Concept 100% 32.44% 33.33% 1 Legal Issues Concept 0% 75.94% 83.33% 0 Mobility Concept 50% 48.7% 50% 1 Nutrition Concept 66.67% 52.58% 61.11% 2 Oxygenation & Gas Exchange Concept 50% 69.88% 50% 1 Perfusion Concept 50% 48.23% 58.33% 1 Professionalism Concept 100% 53.51% 50% 1 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 4/15 Category Name Student Score National Average Class Average Points Status Safety Concept 58.33% 74.62% 78.7% 3.5 Sensory Perception Concept 0% 7.18% 0% 0 Sexuality Concept 100% 92.74% 100% 1 Stress & Coping Concept 100% 82.01% 93.33% 2 Tissue Integrity Concept 75% 70% 33.33% 1.5 Exemplar-Disease 67.23% 65.37% 68.69% 33.616667 Advocacy 100% 40.16% 16.67% 1 Antibiotic Resistant Infection 100% 56.49% 100% 1 Asthma 0% 68.6% 16.67% 0 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 5/15 Category Name Student Score National Average Class Average Points Status Care Coordination 60% 70.53% 73.33% 0.6 Chronic Kidney Disease 100% 63.66% 83.33% 1 Deep Vein Thrombosis (DVT) 100% 83.61% 83.33% 1 Devices & Restraints 0% 75.94% 83.33% 0 Diabetes 60% 67.99% 80% 0.6 Documentation 0% 40.66% 66.67% 0 End-of-Life Care 100% 86.48% 66.67% 1 Enteral and Parenteral Nutrition 100% 64.02% 100% 1 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 6/15 Category Name Student Score National Average Class Average Points Status Ethical Principles 100% 53.51% 50% 1 Falls 50% 68.34% 83.33% 1 Fibromyalgia 30.56% 64.17% 58.8% 0.916667 Fluid Overload 100% 93.01% 100% 1 Grief 100% 76.64% 100% 1 Handoff Communication 0% 51.23% 66.67% 0 Heart Failure 100% 71.09% 83.33% 1 Hypertension (HTN) 0% 32.79% 33.33% 0 Isolation Precautions 100% 75.56% 95.83% 2 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 7/15 Category Name Student Score National Average Class Average Points Status Malnutrition 100% 65.71% 83.33% 1 Medication Administration 71.43% 68.02% 73.41% 5 Mobility Techniques & Devices 50% 48.7% 50% 1 Pain: Acute & Chronic 91.67% 74.9% 76.39% 2.75 Patient Education 12.5% 69.99% 58.33% 0.25 Patient Rights & Confidentiality 100% 95.96% 100% 1 Postoperative Care 0% 28.02% 0% 0 Preoperative Care 100% 55.93% 100% 1 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 8/15 Category Name Student Score National Average Class Average Points Status Pressure Injury 100% 72.57% 33.33% 1 Sexually Transmitted Infections (STIs) 100% 92.74% 100% 1 Spinal Cord Injuries 100% 71.16% 83.33% 1 Therapeutic Communication 100% 82.1% 85% 2 Traumatic Brain Injury 100% 32.44% 33.33% 1 Visual Impairment 0% 7.18% 0% 0 Wound Care & Wound Healing 50% 67.43% 33.33% 0.5 Item Type 67.23% 65.37% 68.69% 33.616667 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 9/15 Category Name Student Score National Average Class Average Points Status Calculation 100% 90.07% 83.33% 1 Cloze 25% 68.46% 44.44% 0.5 Highlight 50% 30.4% 50% 1 HotSpot 0% 28.02% 0% 0 Matrix 86.67% 76.12% 77.78% 2.6 Multiple Choice 78.57% 66.93% 75% 22 Multiple Response 54.31% 67.22% 64.91% 6.516667 Ordering 0% 43.35% 50% 0 NCLEX® Client Needs 67.23% 65.37% 68.69% 33.616667 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 10/15 Category Name Student Score National Average Class Average Points Status Basic Care and Comfort 76.85% 65.26% 68.98% 6.916667 Health Promotion and Maintenance 76.67% 70.12% 75.42% 4.6 Management of Care 65.71% 64.89% 62.22% 4.6 Pharmacological and Parenteral Therapies 57.14% 68.25% 63.89% 4 Physiological Adaptation 70% 65.61% 66.67% 3.5 Psychosocial Integrity 66.67% 64.12% 70% 4 Reduction of Risk Potential 60% 56.15% 56.67% 3 Safety and Infection Control 60% 66.96% 88.33% 3 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 11/15 Category Name Student Score National Average Class Average Points Status QSEN Competencies 67.23% 65.37% 68.69% 33.616667 Evidence-based Practice 62.5% 70.64% 67.71% 5 Informatics 50% 47.09% 58.33% 1 Patient-Centered Care 78.65% 69.08% 71.38% 16.516667 Safety 56.67% 60.2% 66.48% 8.5 Teamwork and Collaboration 65% 63.83% 70% 2.6 RN Nursing Process 67.23% 65.37% 68.69% 33.616667 1-Assessment 78.57% 69.71% 75.79% 5.5 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 12/15 Category Name Student Score National Average Class Average Points Status 2-Analysis 64.8% 62.28% 66.81% 11.016667 3-Planning 71.43% 64.46% 64.76% 5 4-Implementation 77.78% 70.53% 71.3% 7 5-Evaluation 51% 63.55% 67.31% 5.1 Specialty Focus 67.23% 65.37% 68.69% 33.616667 Fundamentals 67.23% 65.37% 68.69% 33.616667 System 67.23% 65.37% 68.69% 33.616667 Cardiovascular System 33.33% 62.62% 61.11% 1 Community System 100% 76.64% 100% 1 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 13/15 Category Name Student Score National Average Class Average Points Status Fluid Electrolyte Acid-Base System 100% 71.09% 83.33% 1 Gastrointestinal System 75% 58.06% 68.75% 3 Immune System 100% 57.4% 100% 2 Integumentary System 75% 70% 33.33% 1.5 Leadership System 66.67% 66.51% 68.06% 4 Multisystem 51.94% 66.37% 70.69% 3.116667 Musculoskeletal System 50% 48.7% 50% 1 Neurological System 83.33% 43.51% 52.78% 2.5 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 14/15 Category Name Student Score National Average Class Average Points Status Pain System 68.75% 73.55% 71.18% 2.75 Psychosocial System 81.25% 80.26% 71.67% 3.25 Renal System 100% 78.34% 91.67% 2 Reproductive System 100% 92.74% 100% 1 Respiratory System 50% 69.88% 50% 1 Safety System 58.33% 68.16% 80.09% 3.5 Sensory System 0% 7.18% 0% 0 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 0 50 100 10/21/25, 8:31 PM Exam Taker Portal | Individual Strengths & Opportunites Report https://phx004-student-ui-prod.examsoft.com/course/449865/assessments/1814967/strengths-and-opportunities/2320368 15/15