Lee University School of Nursing – Clinical Judgment
Worksheet
Name __________________________________ Date
________________________
1. Initial change in client condition.
What one piece of data did you recognize?
What time was the change?
2. Additional relevant data.
What is the background for this patient? Admission diagnosis, demographic data,
comorbidities, complications.
What other related data expands the understanding of this change in condition?
(normal and abnormal)
Recent vital signs, trends in vital signs. Include dates/times.
Recent lab and diagnostic data. Include dates/times.
3. Analyze the data.
What is the new problem?
What could the change be caused by? Complication?
What is the related patho for this problem/complication for this specific patient?
What priorities will you set for this problem/complication?
4. Solutions and interventions
What interventions were implemented? What times were they implemented?
What is the rationale for each of these interventions? What is the intended
action of any medications?
Include medications, procedures, nursing care, pt teaching, communication with
other team members.
If the provider was contacted, list the time and new orders received.
5. Client response and effectiveness of interventions.
How did the client data change as a result of the interventions? Identify times.
How have the previously identified data trends changed? Identify times.
This data should relate back to items 1 & 2.
Was this effective or not? Explain why.
6. Follow up
What additional interventions are needed from this point going forward?
Explain the rationale (consider patho, medication actions, possible
complications).
What is the best timing for these interventions to occur?
Grading for Clinical Judgment worksheet
Points based on specificity and completeness of descriptions/explanations, use of correct medical terminology, and
demonstration of critical thinking/application.
Points Section and comments
/5 1. Change in client condition
/25 2. Additional relevant data
/25 3. Analysis of the data
/20 4. Solutions and interventions
/15 5. Client response and effectiveness of interventions
/10 6. Follow up
/100 Total points
KR 2022
