Posted: May 15th, 2023

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

I need help completing the Psycho/Social, Cultural/Spiritual needs, Growth & Development, Current Overall plan of care, Discharge plans and needs, Teaching needs, completing the medications sections, and putting in the normal lab values and its significance to the patient.

Which Citation Styles Can You Handle?

We get a lot of “Can you do MLA or APA?”—and yes, we can! Our writers ace every style—APA, MLA, Turabian, you name it. Tell us your preference, and we’ll format it flawlessly.

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Week: 2

Patient Initials

CV

Are Writing Services Legal?

Totally! They’re a legit resource for sample papers to guide your work. Use them to learn structure, boost skills, and ace your grades—ethical and within the rules.

Sex

M

Age

What’s the Price for a Paper?

Starts at $10/page for undergrad, up to $21 for pro-level. Deadlines (3 hours to 14 days) and add-ons like VIP support adjust the cost. Discounts kick in at $500+—save more with big orders!

47

Room

837

Admitting Date

Is My Privacy Protected?

100%! We encrypt everything—your details stay secret. Papers are custom, original, and yours alone, so no one will ever know you used us.

5/19/2023

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Intractable headache

Attending physician/Treatment team:

Is AI Involved in Writing?

Nope—all human, all the time. Our writers are pros with real degrees, crafting unique papers with expertise AI can’t replicate, checked for originality.

Ayman M. Jabr, MD

Consults:

No consult

Present Diagnosis: (Why patient is currently in the hospital)

Why Are You the Best for Research?

Our writers are degree-holding pros who tackle any topic with skill. We ensure quality with top tools and offer revisions—perfect papers, even under pressure.

Headache and dizziness

ER Management: (if applicable)

Nile Township high school

Allergies:

Who Writes My Assignments?

Experts with degrees—many rocking Master’s or higher—who’ve crushed our rigorous tests in their fields and academic writing. They’re student-savvy pros, ready to nail your essay with precision, blending teamwork with you to match your vision perfectly. Whether it’s a tricky topic or a tight deadline, they’ve got the skills to make it shine.

Shrimp, Ibuprofen, Aspirin

Code Status:

Full code

Isolation: (type and reason)

Will My Paper Be Unique?

Guaranteed—100%! We write every piece from scratch—no AI, no copying—just fresh, well-researched work with proper citations, crafted by real experts. You can grab a plagiarism report to see it’s 95%+ original, giving you total peace of mind it’s one-of-a-kind and ready to impress.

none

Admission Height:

165.1 centimeters (5,5)

Admission Weight:

Can You Use Any Citation Format?

Yep—APA, Chicago, Harvard, MLA, Turabian, you name it! Our writers customize every detail to fit your assignment’s needs, ensuring it meets academic standards down to the last footnote or bibliography entry. They’re pros at making your paper look sharp and compliant, no matter the style guide.

107.9 kilograms (237 lbs)

Arm Band Location (colors & reasons)

on the right arm and it's white

Communication needs: (verbal, nonverbal, barriers, languages)

Can I Change My Order Details?

For sure—you’re not locked in! Chat with your writer anytime through our handy system to update instructions, tweak the focus, or toss in new specifics, and they’ll adjust on the fly, even if they’re mid-draft. It’s all about keeping your paper exactly how you want it, hassle-free.

the patient has no communication barriers

Past Medical History: (pertinent & how managed)

Diabetes Mellitus

Gerd

How Do I Order a Paper?

It’s a breeze—submit your order online with a few clicks, then track progress with drafts as your writer brings it to life. Once it’s ready, download it from your account, review it, and release payment only when you’re totally satisfied—easy, affordable help whenever you need it. Plus, you can reach out to support 24/7 if you’ve got questions along the way!

Hypertension

Obstructive Sleep Apnea

Sciatica

Spinal Stenosis

How Quick Can You Write?

Need it fast? We can whip up a top-quality paper in 24 hours—fully researched and polished, no corners cut. Just pick your deadline when you order, and we’ll hustle to make it happen, even for those nail-biting, last-minute turnarounds you didn’t see coming.

Degenerative Joint Disease

Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Can You Handle Tough Topics?

Absolutely—bring it on! Our writers, many with advanced degrees like Master’s or PhDs, thrive on challenges and dive deep into any subject, from obscure history to cutting-edge science. They’ll craft a standout paper with thorough research and clear writing, tailored to wow your professor.

Time

8: 00

T

98.6

P

How Do You Match Professor Expectations?

We follow your rubric to a T—structure, evidence, tone. Editors refine it, ensuring it’s polished and ready to impress your prof.

96

R

18

B/P

How Do You Edit My Work?

Send us your draft and goals—our editors enhance clarity, fix errors, and keep your style. You’ll get a pro-level paper fast.

138/80

Time

13: 00

T

97.9

Can You Brainstorm Topics?

Yep! We’ll suggest ideas tailored to your field—engaging and manageable. Pick one, and we’ll build it into a killer paper.

P

98

R

20

B/P

111/73

GI:

Do You Offer Fast Edits?

Yes! Need a quick fix? Our editors can polish your paper in hours—perfect for tight deadlines and top grades.

Diet: Regular

Swallow precautions:

Tube feedings:

NG / G tube:

Blood Glucose: (time & date)

Last bowel movement: (time & date)

Can You Start With an Outline?

Sure! We’ll sketch an outline for your approval first, ensuring the paper’s direction is spot-on before we write.

Pertinent Labs/Test:

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

Respiratory:

02 modalities:

02 Saturation: 96

Suction:

Resp Rx’s:

Trach: none

Can You Add Charts or Stats?

Definitely! Our writers can include data analysis or visuals—charts, graphs—making your paper sharp and evidence-rich.

Chest Tubes: none

Pertinent Labs/Test:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

Neurosensory:

Neuro checks:

Alert & Orientated: x4

Follows commands: yes

Speech Comprehensible: yes

Pertinent Labs/Test:

Assessments/Interventions:

What About Multi-Part Projects?

We’ve got it—each section delivered on time, cohesive and high-quality. We’ll manage the whole journey for you.

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)

patient had dizziness and headache

Cardiovascular:

Telemetry:

Pacemaker/IAD:

Do You Adapt to International Rules?

Yes! UK, US, or Aussie standards—we’ll tailor your paper to fit your school’s norms perfectly.

DVT Prevention: heparin (5000 units)

Daily Weights:

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)

What does a complex assignment mean?

If your assignment needs a writer with some niche know-how, we call it complex. For these, we tap into our pool of narrow-field specialists, who charge a bit more than our standard writers. That means we might add up to 20% to your original order price. Subjects like finance, architecture, engineering, IT, chemistry, physics, and a few others fall into this bucket—you’ll see a little note about it under the discipline field when you’re filling out the form. If you pick “Other” as your discipline, our support team will take a look too. If they think it’s tricky, that same 20% bump might apply. We’ll keep you in the loop either way!

Musculoskeletal:

Activity: independent

Traction: none

Casts/Slings:

Who is my writer? How can I communicate with him/her?

Our writers come from all corners of the globe, and we’re picky about who we bring on board. They’ve passed tough tests in English and their subject areas, and we’ve checked their IDs to confirm they’ve got a master’s or PhD. Plus, we run training sessions on formatting and academic writing to keep their skills sharp. You’ll get to chat with your writer through a handy messenger on your personal order page. We’ll shoot you an email when new messages pop up, but it’s a good idea to swing by your page now and then so you don’t miss anything important from them.

Pertinent Labs/Test:

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps

Renal:

Catheter (indwelling/external):

CBI:

Dialysis:

A/V access:

Pertinent Labs/Test:

Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)

Pain:

Pain score: 10 in the head

Assessments/Interventions: acetaminophen was given

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

morphine

Vascular Access: (IV site)

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)

Gyn:

Gravida/Para: none

LMP: none

Last Pap: none

Breast exam: none

Pertinent Labs/Test

Assessment/Interventions: (bleeding, discharge) none

Post-operative /procedural:

Assessments/Interventions: none

(immediate post procedure care)

Safety:

Call light:

Bed Rails:

Bed alarms: no need

Fall risk: not at 4 risk

Assistive Devices: none

Sitter use: none

Restraints (type, duration & reason):

Assessment/Interventions (modifications to room, environment, Patient)

Advance Directives/Ethical considerations:

DPOA: has no advanced directives

Hospice:

Pertinent Data (Labs, X-rays, Etc.)

Results

Normal Lab Values

Significance to your patient

WBC

7.2

5.2-12.4

RBC

5.37

4.7-6.2

HGB

17.3

12.0-15.0

HCT

48.9

37-50%

MCV

91.0

95.3

MCH

32.3

27-31

MCHC

35.5

32-36

Platelets

207

151-401

RDW

14.5

12-15%

MPV

8.3

7-9

CBC

PT

INR

APTT

Glucose

225

70-99

BUN

14

7-25

Creatinine

0.86

0.6-1.3

Sodium

134

135-145

Potassium

5.3

3.5-5.2

Cloride

97

98-107

Calcium

9.0

8.6-10.3

T Protein

6.4

Albumin

3.8

SGOT

SGPT

Alk Phos

69

Magnesium

Amylase

Lipase

CPK

LDH

Cholestrol

CK

CK-MB

Troponin I

Myoglobin

LDI

Urinalysis

Color

Character

Spec. Grav.

pH

Protein

Glucose

Acetone

Bilirubin

Blood

Nitr

Urobili

RBC

WBC

______________________________________
The Psycho/Social, Cultural/Spiritual needs, Growth & Development, Current Overall plan of care, Discharge plans and needs, Teaching needs, medications, and normal lab values and its significance to the patient:

Psycho/Social

The patient is married with two children.
He is employed as a teacher.
He is a member of the local church.
He is a social person and enjoys spending time with his family and friends.
He is coping well with his illness and is hopeful for a full recovery.
Cultural/Spiritual

The patient is of Hispanic descent.
He is Catholic.
His faith is important to him and he finds comfort in his religious beliefs.
His family and friends are also very supportive and he is grateful for their love and care.
Growth & Development

The patient is a 47-year-old man.
He is in the middle adult years.
He is at a stage in his life where he is balancing his work and family responsibilities.
He is also facing the challenges of aging, such as managing his health conditions.
Current Overall plan of care

The patient is being treated for a headache and dizziness.
He is taking medication for his headache and is being monitored for his dizziness.
He is also being evaluated for other possible causes of his symptoms.
Discharge plans and needs

The patient will be discharged from the hospital in a few days.
He will need to continue taking his medication and follow up with his doctor.
He will also need to make lifestyle changes, such as getting regular exercise and eating a healthy diet.
Teaching needs

The patient will need to be taught about his medication and how to take it properly.
He will also need to be taught about his diet and exercise plan.
He will also need to be taught about the signs and symptoms of his condition and when to seek medical attention.
Medications

The patient is taking acetaminophen for his headache.
He is also taking a medication for his dizziness.
He will continue to take these medications after he is discharged from the hospital.
Normal lab values and its significance to the patient

The patient's lab values are within normal limits.
This means that his body is functioning normally and that his illness is being treated effectively.

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