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vSIM ISBAR ACTIVITY STUDENT WORKSHEET

  Li Na Chen Part 1: Admission Li Na Chen Part 2: Discharge

INTRODUCTION/IDENTIFICATION

 

Identify your name, position

   

SITUATION/SUBJECT

 

State patient’s name, age, reason for admission

                

   

BACKGROUND

 

State patient’s primary diagnosis, past history of suicidal or self-harm behaviors, allergies, current orders.

 

   

ASSESSMENT

 

State significant finding of this shift’s bio-psycho-social assessment (include self-harm/other harm, change in functioning, appetite, sleep, ability to complete ADLs, and noted psychosis), pertinent diagnostics (labs, procedures, etc.), vital signs, any PRN medications given during the shift and outcome.

 

   

RECOMMENDATION

 

State any recommendations, nursing interventions, or orders that may need to be addressed.

 

   

 

SCIENCE
HEALTH SCIENCE
NURSING
NRS 3016

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