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Nursing Log Book for Clinical Training

This document contains information about a medical surgical nursing department log book, including instructions for trainees to record their clinical and academic work. The log book is meant to document the trainee's level of competency in skills from needing direct supervision to being competent without supervision. The objectives of the training are for trainees to acquire skills in topics like taking medical histories, performing nursing care plans, and providing holistic patient care. The document also includes examples of forms and assessments used in the training, such as a comprehensive patient history form and method of trainee evaluation.

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Majied Mohamed
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0% found this document useful (0 votes)
276 views17 pages

Nursing Log Book for Clinical Training

This document contains information about a medical surgical nursing department log book, including instructions for trainees to record their clinical and academic work. The log book is meant to document the trainee's level of competency in skills from needing direct supervision to being competent without supervision. The objectives of the training are for trainees to acquire skills in topics like taking medical histories, performing nursing care plans, and providing holistic patient care. The document also includes examples of forms and assessments used in the training, such as a comprehensive patient history form and method of trainee evaluation.

Uploaded by

Majied Mohamed
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • What is a Logbook?
  • Objectives
  • Course Introduction and Description
  • Comprehensive History
  • Investigation Sheet
  • Medical Sheet
  • Intake and Output Chart
  • Nursing Note

LOG BOOK

Medical surgical nursing department

Index
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1 Title page 1
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What is a logbook?

Log book is a day record of the clinical and academic work done by the trainee.

Instruction for filling log book:

1. Entries must commence from the start i.e. DAY ONE of the training
program.
2. Trainees are advised to make the required entries on the day of the event and
get it signed by the supervisor.
For validating the entries in logbooks, a "consultant" is an individual who
has observed / supervised the procedure documented by the trainee.
3. It is the responsibility of the trainee to get the logbook signed by the
approved supervisor as soon as the entries on one page are completed.

Level of competency

i. Level one assistant status.


ii. Level two need direct supervisor.
iii. Level three need indirect supervision.
iv. Level four competent, UN supervised.
Objectives

At the end of semester, the student would acquire the following skills.
1. Ability to take full medical history and assess patient's vital signs.
2. Acquisition of the skills that enable students to perform nursing care
plan.
3. Identify patient problems physical, psychological, and social.
4. Plan for integrated and holistic patient's care in general medical words.
5. Implement nursing care according to identified and constructed plan.
6. Use methods of self-learning to promote abilities and building self-
competence capacity.
Introduction of the course/ course description:-
Nursing administration course is designed to provide the student nurse with the
theoretical knowledge and practical skills focusing on application nursing
administration components using the leadership process. It is consists of theoretical
part in addition to clinical rotation which designed to prepare graduate nurses with
knowledge and skills to be competent in improve nursing services, communication,
comprehensive nursing management to maintain staff development, management
of nursing staff problems in hospitals board as well as using nursing assignment to
improve quality of patients care and plan to achieve the organization goal.
The theoretical education started four weeks earlier before the clinical
training in order to give chance for the students to equip the different scientific
aspects bases up on which clinical training is based. Different items of
administration used in the nursing services and other department also precede this.
The students are evaluated through oral, written, and practical examination
by using observation checklist and the active discussion participation.
Method of evaluation
1. Observe the students' performance using chick list.
2. Nursing administration sheet.
3. Nursing records.
4. Attendance.
5. Uniform.
6. Interpersonal communication with staff and other students.
7. Preparation and presentation of conferences.
8. Counseling and application of administration components.
9. Practical exam.
Comprehensive history
Demographic data
Patient's name:-………………………………………………………………………
Age :-…………………….……………………………………………....
Gender :-…………………………………..…………………………………
Occupation :-…………………………………………………..…………………
Resident :-………………………………………………………………..……
Marital status :-……………………………………………………………………...
Race :-…………………………………………………………………….
Religion :-…………………………………………………………………….
Date of admission:-…………………………………………………………………..
Source of referral:-…………………………………………………………………...
Source of history:-…………………………………………………………………...
Ward :-……………………………………………………………………..

Chief complaint:
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………

Present illness
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
o Past history
 Childhood illnesses:
Measles Rubella Rheumatic fever
Mumps polio Whooping cough
Chickenpox Scarlet fever
 Adult illnesses:
Diabetes Hypertension Asthma
Stroke Kidney disease Tuberculosis
Arthritis Anemia Allergy
o Hospitalization
………………………………………………………………………………………
………………………………………………………………………………………
o Operations:
………………………………………………………………………………………
………………………………………………………………………………………
o Accident and injures
………………………………………………………………………………………
………………………………………………………………………………………

o Blood transfusion
………………………………………………………………………………………
………………………………………………………………………………………

o Long-term medication
………………………………………………………………………………………
………………………………………………………………………………………
o Allergies list if any
…………………………………………………………………………………………….
o Current medication
………………………………………………………………………………………
………………………………………………………………………………………
 Allergies list if any
…………………………………………………………………………………………….
o Family history
Diabetes Hypertension Heart diseases
Asthma Kidney diseases Hypercholesterolemia
Epilepsy Cancer mental illness
The age and heath or age and cause of death, of each immediate family member:
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
Psychological history:
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
Home situation:
………………………………………………………………………………………
………………………………………………………………………………………
Environmental hazard:
………………………………………………………………………………………
………………………………………………………………………………………
Use of safety measures:
………………………………………………………………………………………
………………………………………………………………………………………
Life style:
Diet
Usual daily intake:
………………………………………………………………………………………
………………………………………………………………………………………
Dietary restriction or supplements:
………………………………………………………………………………………
………………………………………………………………………………………
Sleep patterns:
………………………………………………………………………………………
………………………………………………………………………………………
Exercise and leisure activities:
………………………………………………………………………………………
………………………………………………………………………………………
Personal habits:
Tobacco:
1. Cigarettes Amount…………Duration………………
2. Chewing tobacco or snuff Amount…………Duration………………
3. Alcohol, drugs, and Related Amount…………Duration………………
Amount…………Duration………………
Amount…………Duration………………
Screening test:
…………………………………………………………………………….
Immunizations:
Tetanus pertussis diphtheria hepatitis B

Polio Rubella measles pneumococcal

Homophiles influenza

Systemic review:
General

Usual weight recent Wight change weakness

Fatigue fever

Skin

Rashes lumps sores

Color changes changes in hair changes in nails

Itching dryness
Head:
Headache head injury

Eyes:
Vision glasses contact lenses pain
redness excessive tearing spots glaucoma
cataract flashing lights duple vision specks
Blurred vision

Last eyes examination……………………………………………………………….

Ears:
Hearing Tinnitus Earaches

Infection hearing aid discharge

Nose and Sinuses:


Frequent cold Nasal stuffiness itching

Nose bleeds sinus trouble

Mouth and throat:


Condition of teeth bleeding gums
Frequent sore throat sore tongue
Dry mouth
Last dental examination…………………………………………………
Neck:
Lumps pain discomfort

Breast self-examination nipple discharge

Respiratory system:
Cough asthma bronchitis hemoptysis

Pleurisy pneumonia wheezing Emphysema

Last chest X-ray………………………………………………..tuberculosis

Sputum (color and quantity)………………………………………………………

Cardiac:
Tachycardia high blood pressure chest pain

Palpitation Rheumatic fever orthopnea

Edema heart murmurs

Paroxysmal nocturnal dyspnea

Past electrocardiogram or other test result


………………………………………………………………………………………
………………………………………………………………………………………

Gastrointestinal tract:
Nausea Vomiting

Heartburn Appetite

Vomiting of blood Regurgitation

Troubling swallowing Color and size of stool

Hemorrhoid Constipation

Abdominal pain Jaundice


Hepatitis Frequency of bowel movement

Rectal bleeding or black tarry stool Change in bowel habits

Diarrhea Excessive belching or passing of gas

Food intolerance Liver or gallbladder trouble

Urinary system:
Frequency of urination

Nocturia Hesitancy

Incontinence Urinary infection

Polyuria Hematuria

Dysuria Stones

Genital system:
Swelling Pain Redness

Tenderness Stiffness Weakness

Limitation of motion or activity

Neurological:
Fainting Weakness Blackout

Paralysis Seizure

Tingling or pain and needles movements

Tremors or other involuntary movements

Numbness or loss of sensation


Hematology:
Past transfusion and any reaction to them

………………………………………………………………………………………
………………………………………………………………………………………

Easy bruising or bleeding

Anemia

Endocrine:
Thyroid trouble Excessive sweeting

Excessive thirst or hunger Heat or cold intolerance

Diabetes Polyuria

Psychiatric:
Nervousness Tension

Mood including Depression

Memory loss Aggressive behavior


Investigation sheet

Patient's name…………………………………..………… Age……………..

Diagnosis………………………………………………………………………

investigation Result comments Time and date Signature


Medical sheet

Patient's name…………………………………..………… Age……………..

Diagnosis………………………………………………………………………

Drug name Route Dose Start at Discontinue at Time and Signature


date
Patient's name…………………………………..………… Age……………..

Diagnosis………………………………………………………………………

Intake output Time Signature

oral parenteral Urine Others

Total intake= Total output=

Comment:

………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
Nursing note

Patient's name…………………………………..………… Age……………..

Diagnosis………………………………………………………………………

Nursing diagnosis Nursing goal Nursing intervention Nursing evaluation

Good luck

Common questions

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The nursing program integrates self-learning approaches by encouraging students to independently identify and solve patient problems, supporting skill development through self-directed learning . By using methods of self-learning, students enhance abilities and build self-competence capacity, which is crucial for lifelong learning in nursing. Additionally, active discussions and preparation for conferences foster an environment where students engage in critical thinking and knowledge application, further promoting self-learning . This approach not only builds competence but also encourages adaptability and problem-solving skills essential for nursing practice .

The theoretical foundation established in the initial four weeks equips nursing students with essential scientific knowledge and theoretical frameworks needed for clinical practice . It provides a comprehensive understanding of nursing principles, administration components, and leadership processes before clinical exposure, ensuring students are well-prepared and knowledgeable. This preclinical education supports informed decision-making and effective patient care during clinical rotations, essential for developing clinical competence and confidence . It serves as a critical underpinning for the practical application of skills and reinforces learning through direct patient interaction .

The evaluation process is comprehensive as it incorporates multiple assessment methods, including performance observation using checklists, administration sheet analysis, nursing records evaluation, and practical exams . This multifaceted approach allows for assessing both theoretical knowledge and practical skills. The process also includes oral and written exams, student participation in conferences, and interpersonal communication evaluation, offering a thorough assessment of clinical and administrative competencies . Combined, these methods ensure a holistic evaluation of student capabilities across different nursing domains .

The nursing administration course prepares students by offering a blend of theoretical knowledge and practical skills focused on nursing administration components, using the leadership process . It includes a clinical rotation designed to equip students with competencies necessary for improving nursing services and patient care quality. The course covers communication, comprehensive nursing management, and problem-solving with nursing staff, which are vital for efficient hospital management . Furthermore, pre-clinical theoretical education allows students to build a scientific knowledge base, enhancing their readiness for clinical training .

By the end of the nursing program, students are expected to have competencies such as the ability to take full medical histories, assess patient vital signs, and perform nursing care plans . These competencies align with skills required for integrated patient care as they enable students to identify patient problems holistically, including physical, psychological, and social aspects. Students also learn to implement nursing care according to constructed plans and employ self-learning methods to enhance their competence, which are crucial for delivering integrated and patient-centered care .

Requiring immediate recording and validation of logbook entries ensures accuracy and timeliness, helping trainees capture real-time observations and insights, reducing errors attributed to memory lapses . It encourages accountability and reflection on daily occurrences, reinforcing learning. However, the challenge lies in maintaining diligent recording amid demanding clinical responsibilities, which can be time-consuming . Immediate validation requires consistent supervisor availability, which may sometimes be logistically difficult due to conflicting schedules .

The instructions for filling out the logbook ensure transparency and accuracy by requiring entries to commence from Day One of the training program and be made on the day of the event . Trainees must obtain signatures from supervisors, who validate the observations and procedures documented, marking an official acknowledgment of the trainee's work . This system minimizes discrepancies and enhances accountability, as supervisors must directly observe or supervise the procedures logged, ensuring all recorded information is correct and verified .

The consultant plays a crucial role in validating logbook entries, ensuring the accuracy and credibility of the recorded clinical experiences . By providing direct observation or supervision, consultants confirm that the procedures and experiences documented by trainees meet clinical standards, contributing to the integrity of the training process. This validation step not only holds trainees accountable but also elevates the quality of training by ensuring that all logged experiences are legitimate and valuable for skill development . The involvement of consultants thus maintains high educational and professional standards, pivotal in preparing competent nurses .

The primary purpose of a logbook in medical-surgical nursing training is to serve as a day record of the clinical and academic work done by the trainee. It ensures that trainees document their activities and acquire sign-off from supervisors to validate their experiences . This process aids in tracking the trainee's progress and supports the development of clinical competencies by mandating active engagement and reflection on daily tasks. The structured approach of maintaining a logbook helps trainees identify areas for improvement, thereby contributing to their professional growth and proficiency in nursing skills .

The structured approach to competency levels in the logbook facilitates progressive skill acquisition, with Level 1 indicating an assistant status and Level 4 representing unsupervised competence . This tiered system allows students to advance through different stages of supervision, fostering independence over time. Trainees start with direct supervision at Level 2, proceed to indirect at Level 3, and eventually reach full competence, preparing them for real-world nursing scenarios without reliance on constant oversight . This progressive framework serves as a roadmap for skill development, ensuring readiness for independent practice .

LOG BOOK
Medical surgical nursing department
Index 
NO
content
page
1
Title page
1
2
Index 
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
What is a logbook?
Log book is a day record of the clinical and academic work done by the trainee.
Instruction for filling lo
Objectives
At the end of semester, the student would acquire the following skills.
1. Ability to take full medical history an
Introduction of the course/ course description:-
Nursing administration course is designed to provide the student nurse with
Comprehensive history
Demographic data
Patient's name:-………………………………………………………………………
Age                   :-…………………….………………………
o Past history 
 
 
Childhood illnesses:
 
 
Measles                             Rubella                            Rheumati
…………………………………………………………………………………………….
o Family history
 
 
Diabetes                          Hypertension
Exercise and leisure activities:
………………………………………………………………………………………
………………………………………………………………………………………
Personal habits:
Tobacco
Head:
Headache                                       head injury
Eyes:
Vision                          glasses contact

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