SHCTC Junior Hospital EHR

Open Assigned Patient

Student nameAssigned patient

Verify two patient identifiers, allergies, and precautions before beginning. Use only simulated information.

Patient Overview / Brain

Open a patient to begin.

Documentation Timeline

No entries filed.

Admission Intake

Chief complaintHistory of present illnessMedical/surgical historyHome medicationsMobility / fall riskNutrition / swallowingSkin on admissionSafety / communication needs

Provider Orders & Laboratory Results

Active Orders

Orders reviewed

Results

Test	Result	Flag

Important result and follow-up

Vital Signs

Temperature °FPulse /minRespirations /minBPSpO₂ %OxygenPositionMethod

Comments / action

Time	T/P/R	BP	SpO₂/O₂	Method	Comments

Blood Glucose / POC

Glucose mg/dLTimingSymptoms

Action / notification

Time	Result	Timing	Symptoms	Action

Head-to-Toe Assessment

Chart only what you assessed. Selecting an abnormal finding requires a description.

Clinical Skills Documentation

Time	Skill	Result	Follow-up

Pain Assessment & Reassessment

Score 0–10LocationQualityOnset

Aggravating / relieving factorsIntervention / notification

Time	Score	Location/Quality	Action/Response

Lines, Drains, Airways & Wounds

DeviceLocationSite/condition

Assessment / intervention

LocationTypeDrainage

Wound bed, surrounding skin, dressing

Medication Administration Record — Simulation

Simulation only. Never administer a real medication based on this training chart.

Medication order	Pre-check	Status	Reason/response

Intake & Output

Oral intake mLIV intake mLUrine mLOther output mL

Source / comments

No intake or output documented.

Nursing Notes

S — SubjectiveO — ObjectiveA — Assessment/identified concernP — Plan/follow-up

Student Care Plan

Patient problem / nursing concernEvidence / supporting dataGoal / expected outcomeInterventions

Evaluation / patient response

SBAR / Handoff

SituationBackgroundAssessmentRecommendation / Request

Discharge Documentation

DispositionCondition at dischargeMedication teachingDiet/activity instructionsFollow-up / appointmentsWarning signs / when to seek help

Teach-back response

Open Assigned Patient

Patient Overview / Brain

Documentation Timeline

Admission Intake

Provider Orders & Laboratory Results

Active Orders

Results

Vital Signs

Blood Glucose / POC

Head-to-Toe Assessment

Clinical Skills Documentation

Pain Assessment & Reassessment

Lines, Drains, Airways & Wounds

Medication Administration Record — Simulation

Intake & Output

Nursing Notes

Student Care Plan

SBAR / Handoff

Discharge Documentation

Instructor Review / Encounter Completion