PRAC 6631 WEEK 6 ASSIGNMENT: CLINICAL HOUR AND PATIENT LOGS (12 PATIENTS)

CLINICAL HOUR AND PATIENT LOGS

Clinical Hours

For this course, all practicum activity hours are logged within the Meditrek system. Hours completed must be logged in Meditrek within 48 hours of completion in order to earn the points allocated for this assignment. You may only log hours with preceptors that are approved in Meditrek.

Students must complete a minimum of 160 hours of supervised direct patient clinical experience. You will enter your approved preceptor and clinical faculty as part of each time and patient encounter you log.

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Your clinical hour log must include the following:

Dates

Course

Clinical Faculty

Approved Preceptor

Total Time (for the day)

Notes/Comments

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

PATIENT LOG

Throughout this course, you must keep a log of every patient that you encounter in clinical using Meditrek. You must record at least 120 patients by the end of this practicum.

The patient log must include the following:

Date

Course

Clinical Faculty

Approved Preceptor

Patient Number

Client Information

Visit Information

Practice Management

Diagnosis

Procedure (Note: Make sure that, as you perform procedures at your practicum site, you also note those on your printed-out Clinical Skills List.)

Treatment Plan and Notes

BY DAY 7

Record your clinical hours and patient encounters in Meditrek.

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Rubric

PRAC_6531_Week5_Assignment2_Rubric

PRAC_6531_Week5_Assignment2_Rubric

Criteria Ratings Pts

This criterion is linked to a Learning OutcomePart 1: Time logs and patient logs are completed within 48 hours of completing clinical time.

5 pts

Excellent

*Time logs are completed within 48 hours of completing clinical time. *Patient logs are completed within 48 hours of completing clinical time.

0 pts

Poor

*Time logs are completed more than 48 hours after completing clinical time. *Patient logs are completed more than 48 hours after completing clinical time.

5 pts

This criterion is linked to a Learning OutcomeThis criterion is linked to a Learning OutcomePart 2: Patient logs meet the minimum documentation requirements. *Each entry includes Date, Course, Clinical Instructor, Preceptor, Patient number, Client information, Visit information, Practice management, Diagnosis, Procedures (if applicable), Treatment plan and notes, Notes section (Students must include a brief summary/synopsis of the patient visit—this must include enough information to understand how the patient presnted and the student intervention. Do NOT include EMR SOAP notes. *LOGS MUST BE SUBMITTED WITHIN 48 HOURS TO BE ELIGIBLE FOR ANY POINTS

5 pts

Excellent

*Patient logs include all of the required documentation elements.

0 pts

Poor

*Patient logs do NOT include all of the required documentation elements. There are some elements missing or the logs are incomplete. *Patient logs were submitted more than 48 hours after completion of the clinical time.

5 pts

Total Points: 10

Clinical Hour and Patient Logs
Name: M.N.
Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Tinea capitis
S: M.N. is a 20-year-old client who visited the facility with complaints of severe scalp itchiness for the past three days. He reported patches of hair loss that were experienced a month ago. He denied fever, headache, or lymphadenopathy.
O: T 98.6, RR 20, BP 110/68, P 78, SPO2 96%. On examination, the scalp was swollen with some red patches, and some parts had scaly rashes. There was also alopecia and moderate dandruff.
A: Tinea capitis
P: The patient was prescribed topical terbinafine once daily for one month.

Name: E.T.
Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Chronic pain
S: E.T. is a 22-year-old male who came to the facility with complaints of persistent joint pain after suffering from muscle strain a week ago. The patient reported an on-off pattern in his joint pain. He has been managing pain with warm compresses of the affected joint.
O: T 98.7, RR 20, BP 112/70, P 64, SPO2 98%. On examination, his left ankle was swollen, warm to touch with no evidence of bleeding or tissue breakdown. The patient was weight-bearing on the affected extremity.
A: Chronic pain secondary to soft tissue injury
P: the patient was prescribed oral Tylenol 1 g thrice daily for three days.

Name: F.T.
Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Insomnia
S: F.T. is a 28-year-old female who visited the facility with complaints of being a poor sleeper for the last five months. F.T. reported that she sleeps an average of three hours every night. She has tried mindfulness and relaxation techniques but unsuccessful. The sleep problem has affected her productivity as a teacher. She denied alcohol or substance abuse
O: T 98.6, RR 18, P 74, BP 124/70, SPO2 98%. On examination, the patient appears fatigued with no evidence of illness.
A: Insomnia rule out major depression
P: The patient was prescribed oral zolpidem 25 mg once daily for one month and scheduled for a follow-up visit after seven days to assess response to treatment.

Name: R.S.
Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Uncomplicated community-acquired pneumonia
S: R.S. is a 40-year-old female client who came to the facility with complaints of chest pain, fever, cough, and loss of appetite for the last five days. She reported that the chest pain worsens with coughing or inspiration. She denied the use of any medications for the symptoms.
O: T 99.0, RR 24, SPO2 96%, BP 126/78, P 80. On examination, the patient was acyanotic, reported chest pain rated 6/10, productive cough, and appeared fatigued. Chest x-ray and sputum culture were performed. A diagnosis of community-acquired pneumonia was made based on the diagnostic findings.
A: Community-acquired pneumonia
P: The patient was prescribed IV ceftriaxone 2 g stat plus oral azithromycin 500 mg for one day followed by 250 mg q24h for four days. She was scheduled for a follow-up visit after six days to assess treatment response.

Name: D.D.
Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Gastritis
S: D.D. is a 32-year-old client who visited the facility with complaints of stomach pain for the last three days. She noted accompanying symptoms that included belching, nausea and vomiting, decreased appetite, and a feeling of fullness in her stomach. She reported using antacids, which provided short-term relief.
O: T 98.6, RR 20, BP 120/78, P 60, SPO2 98%. On examination, bowel sounds were present and normoactive in all four quadrants with no evidence of abdominal swelling or rebound tenderness.
A: Gastritis
P: The patient was prescribed oral omeprazole 20 mg once daily for one week.

Name: M.U.
Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Allergic rhinitis
S: M.U. is a 35-year-old client who visited the facility with complaints of itchy and runny nose for the last four days. He also reported a cough, sneezing, and watery eyes. He denied pain or the use of any symptom-relief medications at home.
O: SPO2 96%, RR 22, P 76, BP 118/68. On examination, there was clear nasal drainage, watery eyes, and no post-nasal drainage or exudates. There was no sinus tenderness or nasal septum deviation.
A: Allergic rhinitis
P: The patient was prescribed oral cetirizine 10 mg once daily for five days for symptom relief.

Name: O.M.
Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Skin abscess
S: O.M. is a 24-year-old male client who presented to the facility with complaints of swelling in his cheek. He reported that the swelling started three days ago. The swelling is painful, warm to the touch, and filled with fluid. He denied fever or chills.
O: T 98.7, RR 18, P 68, BP 114/64, SPO2 98%. On examination, there was a red skin swelling on his left cheek. The swelling was pus-filled, and warm to the touch. Incision and drainage were performed.
A: Skin abscess
P: The patient was prescribed oral fluconazole 500 mg QID for five days and oral Tylenol 1 g TDS for three days.

Name: R.S.
Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Mastitis
S: R.S. is a 32-year-old postnatal woman who visited the facility for a breast examination. She reported breast pain, swelling, fever, and skin redness for the past two days. She has not used any medications for symptom relief.
O: T 99.2, RR 22, P 82, BP 126/68, SPO2 98%. On examination, the right breast was swollen, red, warm, and tender to the touch. The breast tissue was thickened with no abnormal discharge or nipple changes.
A: Mastitis
P: The patient was prescribed oral Tylenol 1 g thrice daily for three days and oral flucloxacillin 500 mg QID for five days. She was scheduled for a follow-up visit after five days to assess her response to treatment.

Name: D.R.
Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Strep throat
S: D.R. is a 24-year-old male client who visited the facility with complaints of a sore throat for the past three days. The reported accompanying symptoms included pain with swallowing, low-grade fever, and reduced appetite. He reported the use of over-the-counter ibuprofen with minimal relief.
O: T 99.0, RR 20, BP 120/72, P 76, SPO2 98%. On examination, there was pharyngeal edema with tonsillar hypertrophy with exudates. There was also anterior cervical lymphadenopathy. A throat swab for culture and sensitivity was taken.
A: Strep throat/pharyngitis
P: Oral amoxicillin 500 mg thrice daily for five days and oral Tylenol 1 g thrice daily for three days were prescribed for the client.

Name: V.N.
Age: 18-65 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Contact dermatitis
S: V.N. is a 25-year-old male client who presented to the hospital with complaints of itchy skin for the last three days. He reported that he has been having an itchy rash and swelling on his right arm. He denied any use of relief medications for symptom management.
O: T 98.6, RR 18, SPO296%, P 68, BP 122/77. On examination, there were rashes in the posterior aspect of his right hand. The rashes were fluid-filled. They were not spread to other body parts.
A: Contact dermatitis
P: The patient was prescribed clobetasol 0.05% skin ointment to be applied twice daily for five days.

Name: N.A.
Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Uncomplicated urinary tract infection
S: N.A. is a 29-year-old female client who visited the facility with complaints of a burning sensation with urination. The patient reported frequent urination with incomplete bladder emptying. She denied abdominal pain, fever, blood in urine, or chills.
O: T 98.6, BP 108/68, P 70, RR 18, SPO2 98%. A urine sample for urinalysis and urine culture was taken. Results revealed the presence of leucocytes and nitrites in the urine sample.
A: Urinary tract infection, rule out cystitis
P: The patient was prescribed oral nitrofurantoin 100 mg and Tylenol 500 mg thrice daily.

Name: G.G.
Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Scabies
S: G.G. is an 18-year-old female client who presented to the facility with complaints of itchy skin. The patient has skin itchiness that worsens at night. The itching is so intense that it impairs her normal sleep pattern. She also reported skin sores due to scratching.
O: T 98.6, RR 22, BP 118/78, P 80, SPO2 98%. On examination, there were sores on the arms and hands due to scratching. There were also some skin crusts on the right arm. A microscopic skin examination confirmed the diagnosis of scabies.
A: Scabies
P: The patient was prescribed Permethrin cream 5% for skin application twice weekly every week. The follow-up visit was scheduled after two weeks.