Drug Study Form

Patient’s Name: ____________________________________ Bed No.

_________________

Medical Diagnosis: _________________________________ Date: ___________________

Brand Name Generic Name Mechanism of Indication Contraindication Side Effects Adverse Dosage Nursing
Action Effects Ordered Responsibilities

Submitted By: Submitted To: Reference:

___________________________________________ ________________________________________ ___________________________________________

Printed Name, Designation and Signature of Student Signature of Clinical Instructor Name of Book, Edition, Copyright and Author
Laboratory Analysis
Patient’s Name: ____________________________________ Bed No.
_________________

Medical Diagnosis: _________________________________ Date: ___________________

Test and Date Actual Result Normal Value Significance of the Result Interpretation Nursing Interventions
Components

Submitted By: Submitted To: Reference:

___________________________________________ ________________________________________ ___________________________________________

Printed Name, Designation and Signature of Student Signature of Clinical Instructor Name of Book, Edition, Copyright and Author
 PROCESS RECORDING ACTIVITY

Observation of Setting Analysis and Recommendations

(Describe the general appearance of the patient and the location (Identify what facilitated the exchange, what were barriers)
where the interview took place. Include the time and place.)

Facilitators:

Barriers:

Interviewer: (Student) Interviewee: (Mrs. M.) Identify Communication Analysis of Interaction

Technique (Was technique effective, why or why not? Was there anything else that
could have been explored?)

“Good morning Mrs. M. We’re “Sure, come on in. You can just go Providing Information Telling Mrs. M. what she was doing would put her at ease and make her feel
going to go ahead and start the ahead and do anything you want, safe and secure.
short interview that we talked about honey.” (smiling)
yesterday, if that’s okay with you.”
(using direct eye contact and a
friendly tone of voice)

Student pulls up a chair and sits Student positioned herself for • Enhances trust
near the head of the bed at active listening (SOLER) Facilitates communication
patient’s eye level) • Conveys interest and involvement
• Eye contact conveys sincerity, interest, and professionalism
• To seek information
 EVALUATION
(What is your overall impression of this communication exchange? Was the goal of the interview achieved? Were there any recurring themes in the exchange? What were the
interviewer’s strengths or weaknesses? What was the social value of this exchange?)

This process recording conveyed that

All in all the interaction was therapeutic,

My goals for further communication growth would be:

1.
2.

Submitted By: Submitted To: Date:

___________________________________________ ________________________________________ ___________________________________________

Printed Name, Designation and Signature of Student Signature of Clinical Instructor