SAMPLE. TAFE NSW HLT51612 Diploma of Nursing (Enrolled/Division 2 Nursing) Course Clinical Record Book Workplace Component

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Aubrie Stafford
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Course 14393 Student Name: Clinical Record Book

1 HLT07 Health Training Package V5 TAFE NSW HLT51612 Diploma of Nursing (Enrolled/Division 2 Nursing) Course Student Name: Clinical Record Book Workplace Component Version 2 Ramsay Health Care Product Code: 5813

2 The State of New South Wales, Department of Education and Training, TAFE NSW, Training and Education Support Industry Skills Unit, Meadowbank, Copyright of this material is reserved to TAFE NSW Training and Education Support Industry Skills Unit, Meadowbank. Reproduction or transmittal in whole or in part, other than for the purposes of private study or research, and subject to the provisions of the Copyright Act, is prohibited without the written authority of, TAFE NSW. Training and Education Support Industry Skills Unit, Meadowbank. ISBN: TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2014

3 Contact Details Student Enrolled Nurse details Hospital details Passport Sized Photo here: Student enrolled nurse s name:... TAFE college:... Enrolment date:... Commencement date:... Student number: Completion date: Details of TAFE NSW person to contact: Name: Head teacher s contact details: Phone Number Hospital name:... Hospital address:... Workplace contact name:... Designation:... Workplace contact phone number:... Head teacher s name: Phone Number TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2014 Page 3 of 84

4 Table of contents This clinical record book is for recording your progress towards completing the HLT51612 Diploma of Nursing (Enrolled/Division 2 Nursing) Course It is divided into the following sections: SECTION ONE: INSTRUCTIONS FOR USING THE CLINICAL RECORD BOOK... 5 Process for unsafe practice in clinical area... 9 SECTION TWO: NATIONAL COMPETENCY STANDARDS Process for students not demonstrating competency standards Core Skills for Work Developmental Framework SECTION THREE: SUMMARY OF CLINICAL SKILLS OBSERVED & PRACTISED IN THE WORKPLACE SECTION FOUR: SUMMARY OF WORKPLACE EXPERIENCE SECTION FIVE: CLINICAL PLACEMENT ATTENDANCE LOG SECTION SIX: RECORD OF CLINICAL SKILLS LINKED TO UNITS OF COMPETENCY DEMONSTRATED AND PRACTISED AT TAFE NSW NMBA Nursing Practice Decision Flowchart SECTION SEVEN: CLINICAL OBJECTIVES FOR PROFESSIONAL EXPERIENCE Clinical Objectives for BASIC NURSING CARE: MANDATORY Clinical Objectives for ACUTE SURGICAL NURSING CARE: MANDATORY Clinical objectives for PERIOPERATIVE NURSING Clinical objectives for MATERNAL and CHILD NURSING Clinical objectives for PAEDIATRIC NURSING Clinical objectives for MENTAL HEALTH NURSING Clinical objectives for COMMUNITY NURSING Clinical objectives for AGED CARE NURSING Clinical objectives for PSYCHOGERIATRIC NURSING Clinical objectives for DEVELOPMENTAL DISABILITY NURSING Clinical objectives for REHABILITATION NURSING Clinical objectives for ABORIGINAL MEDICAL SERVICE (AMS) SECTION EIGHT: WORKPLACE HOLISTIC ASSESSMENT CHECKLISTS Page 4 of 84 TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank)

5 SECTION ONE: INSTRUCTIONS FOR USING THE CLINICAL RECORD BOOK This Clinical Record Book is designed to link the learning component of training to the professional experience environment and to meet the clinical requirements to successfully complete the TAFE NSW HLT51612 Diploma of Nursing (Enrolled/ Division 2 Nursing) course This book is to be used to capture information regarding your professional experience placement and clinical skills required. Student enrolled nurse s responsibilities It is your responsibility to have the Clinical Record Book on each occasion when you are in the clinical workplace. You will need to arrange with your assessor when you wish to be assessed. You must reflect on your clinical performance with the aim to improving your skills. NSW Health sets out mandatory requirements and procedures for employment screening to fulfil a duty of care to vulnerable patients and clients. Please review the NSW Ministry of Health Policy Directive for Employment Checks. Full details of NSW Ministry of Health vaccination requirements are in the NSW Ministry of Health Policy Directive for Occupational Assessment, Screening and vaccination Against Specific Infectious Diseases. This directive is available from Please review the following TAFE NSW Policy for information on safe and ethical practice during student workplace learning. Please review the Code of Ethics, Code for Professional Conduct for nurses and Professional boundaries that are available on the following website. Please review the Nursing Decision Making Framework from NMBA, Codes and Guidelines. This Framework will be useful throughout your career as you make decisions about your nursing practice in a range of different contexts. Available from the following website Clinical Placement This Clinical Record Book contains Clinical Objectives for completion during your clinical placements. Your TAFE NSWor Ramsay Facilitator will review your progress with these objectives. The Basic Care and Acute Surgical Objectives are mandatory for completion. Please ensure that the Clinical Record Book: is kept in a safe place does not have any pages removed, defaced or altered in any way TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2014 Page 5 of 84

6 if lost, you contact your head teacher and present a Statutory Declaration to obtain a replacement book (this may incur a cost). Role of the TAFE NSW or Ramsay Facilitator The TAFE NSW or Ramsay Facilitator will meet with you during professional experience placement. The role of the TAFE NSW or Ramsay Facilitator is to liaise with clinical staff and assist you to achieve the most from your professional experience. The TAFE NSW or Ramsay Facilitator will review your progress with the Clinical Objectives for the specific placement as well as the Specific Criteria Tables contained in the clinical record book. The TAFE NSW or Ramsay Facilitator will liaise with the clinical staff to collect information regarding your clinical performance and attributes required for work. Feedback will be obtained regarding your ability to demonstrate the Core Skills for Work and the Enrolled Nurse Competency standards. Satisfactory progress with clinical objectives, specific criteria tables, observation of clinical skills and the Holistic Assessment Events are required to successfully complete the workplace module which is essential for course completion. Your workplace facilitator/ assessor MUST comply with all relevant and current legislation and refer to the Work Health and Safety Act TAFE NSW or Ramsay Approved Assessors The assessor must provide clear and constructive feedback to the student regarding the assessment decision. If required, the assessor should develop a follow-up action plan with the student. The plan could include gap training or further learning and additional practise opportunities. Assessment of the students must take place within a TAFE NSW approved health care facility and the Registered Nurse must hold the required competencies to undertake the assessment. The competencies required by the assessor are the Certificate IV in Training and Education (TAE 10) or the Assessor Skill Set from the TAE qualification. The Ramsay assessor must also: Be a Registered Nurse with a current authority to practice with two (2) years post registration experience either full-time or equivalent or be a clinical nurse educator or clinical nurse specialist and Have their name on the Assessor database [held by the relevant TAFE NSW institute] Page 6 of 84 TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank)

7 As part of this course you are required to undertake and be observed performing the following: 1. Holistic assessment To successfully complete the Holistic Assessment you must demonstrate satisfactory performance on a minimum of three (3) separate occasions during your professional experience placements. The three occasions will be used to collect evidence of the workplace application of your skills and knowledge during your Basic Nursing, Acute Surgical Nursing and an Additional Placement. This assessment is to assess your interaction with patients, your communication skills and application of clinical skills. Assessment of these skills and the feedback that is required from the nursing staff in the health care facility will provide the evidence required for satisfactory completion of the workplace clinical practice component, related units of competency, enrolled nurse competency standards & demonstration of Core Skills for work. Satisfactory performance must be demonstrated in each of these assessments to achieve competency in the linked units and enable your continuation in the course. 2. Observation of skills You will be required to be observed performing the following clinical skills that have been assessed in TAFE NSW simulated laboratories, in the professional experience environment. The medication administration skills are to be observed whilst you are under the supervision of the registered nurse. These skills should be observed more than once for you to demonstrate application of the skills in different contexts: 1. Hand hygiene 2. Manual handling/ risk assessment 3. Assessing and recording temperature, pulse, respirations 4. Assessing and recording blood pressure 5. Performing urinalysis 6. Blood glucose monitoring (BGL) 7. Aseptic dressing technique 8. Neurological observations 9. Checking S8 medications 10. Administration of medication Oral - minimum four (4) clients per round 11. Administration of medication - IMI or SCI 12. Administration of medication- IV TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2014 Page 7 of 84

8 Specific Criteria To provide direction and focus for your clinical placement each unit of competency has been explored to extract specific criteria for you to observe, discuss or perform. Some skills may overlap in several clinical placements and you must become familiar with the range of criteria included. These items are placed in tables following the list of clinical objectives for specific placements. You will be required to observe, discuss and if the task falls within the scope of practice for a student enrolled nurse at the particular health care facility, and you have received theoretical and practical demonstration, you may be able to perform the skill. If the activity cannot be observed or performed in the workplace you should seek an opportunity to discuss the issue with your TAFE NSW or Ramsay Facilitator. Your TAFE NSW or Ramsay Facilitator will review your progress with the completion of the Specific Criteria Table. The specific criteria listed for Basic and Acute surgical nursing is mandatory and must be completed. It is expected that if you have a specialist placement area that has specific criteria listed, you will make every effort to complete these additional areas. Satisfactory progress with clinical objectives, specific criteria tables and workplace assessments are required to successfully complete the workplace module which is essential for course completion. Client Safety Client safety is a priority with your professional experience. If you are not achieving competencies or demonstrate unsafe practice in the clinical area at any time, steps will be taken to determine the level of risk to the client. Planned actions will be put into place to provide you with every opportunity to improve your practice. If satisfactory progress cannot be demonstrated in the specific areas you will fail your clinical module and will be unable to complete the course. Please refer to the following flowchart. Page 8 of 84 TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank)

Process for unsafe practice in clinical area Process for student not achieving competencies or demonstrating unsafe practice in clinical area Specific details of incident

risk Student asked to reflect on incident and discuss outcomes with TAFE Facilitator Documentation of incident, plan of action, process, timeframes and outcomes recorded

outcomes will need to be achieved within time frames set Immediate notification to appropriate body and student removed from client contact or care facility Documentation

plan of action, process, required outcomes and timeframes documented Assessment in simulated environment and evaluation of risk potential health Satisfactory progress

Review of student s performance against outcomes required Evaluation and assessment of student s performance in clinical environment including feedback from health care

9 Process for unsafe practice in clinical area Process for student not achieving competencies or demonstrating unsafe practice in clinical area Specific details of incident collected by TAFE NSW Facilitator from health care facility staff and student Health care facility staff and TAFE NSW Facilitator determines level of risk Low risk High risk Student asked to reflect on incident and discuss outcomes with TAFE Facilitator Documentation of incident, plan of action, process, timeframes and outcomes recorded by TAFE Facilitator in student s file Student to sign and keep a copy of the plan of action and required outcomes and be informed that to continue in the course these outcomes will need to be achieved within time frames set Immediate notification to appropriate body and student removed from client contact or care facility Documentation of incident in student s file Student returned to simulated environment Revision of client safety issues Revision and supervised practice of required components Agreed plan of action, process, required outcomes and timeframes documented Assessment in simulated environment and evaluation of risk potential health Satisfactory progress Satisfactory outcomes achieved Student continues clinical placement Unsatisfactory outcomes achieved Follow High risk process Supervised return to clinical environment Review of student s performance against outcomes required Evaluation and assessment of student s performance in clinical environment including feedback from health care facility staff Unsatisfactory progress Student has failed clinical module and cannot complete the course TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2014 Page 9 of 84

10 SECTION TWO: NATIONAL COMPETENCY STANDARDS The Australian Nursing and Midwifery Council (2002) National Competency Standards for the Enrolled Nurse. The Australian Nursing and Midwifery Council (ANMC) National Competency Standards for the Enrolled Nurse (2002) are the professional standards which underpin this course along with industry standards. These competencies establish the limits and role boundaries of enrolled nurse practice and are strictly adhered to in this program. These competency standards are aligned to the units in this course. During your Holistic Assessment and whilst you are observed in the professional experience environment you must demonstrate these competency standards to successfully complete this course. There are 10 competency standards that are defined and endorsed by registering bodies in Australia. These competencies underpin enrolled nursing practice. Full details of these standards are contained in your Student Information Book. These competencies will be signed off by the Head Teacher or Course Coordinator following successful completion of the theoretical and clinical component of the course. If a student has not demonstrated the criteria within each competency an individual student contract will be negotiated and completed before a student can successful course complete. Student s name: Competency unit 1: Competency unit 2: Competency unit 3: Competency unit 4: Competency unit 5: Competency unit 6: Functions in accordance with legislation, policies and procedures affecting enrolled nursing practice. Conducts nursing practice in a way that can be ethically justified. Conducts nursing practice in a way that respects the rights of individuals and groups. Accepts accountability and responsibility for own actions within enrolled nursing practice. Demonstrates critical thinking in the conduct of enrolled nursing practice. Contributes to the formulation of care plans in collaboration with the registered nurse, individuals and groups. Demonstrated YES/ NO Head Teacher /Course Coordinator signature Competency unit 7: Competency unit 8: Manages nursing care of individuals and groups within the scope of enrolled nursing practice. Contributes to the promotion of safety, security and personal integrity of individuals and groups Page 10 of 84 TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2014

11 Student s name: within the scope of enrolled nursing practice. Demonstrated YES/ NO Head Teacher /Course Coordinator signature Competency unit 9: Competency unit 10: Provides support and care to individuals and groups within the scope of enrolled nursing practice. Collaborates with members of the health care team to achieve effective health care. YES Student successfully completed all course requirements and graduates from course Process for students not demonstrating competency standards TAFE NSW Head Teacher confirms student has completed all theoretical and clinical components of course Successful demonstration of competency standards Student has not demonstrated all ANMC competency standards Individual student contract completed including: Agreed plan of action, process, required outcomes and timeframes Student cannot complete the course NO Student unable to demonstrate competency standards TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2014 Page 11 of 84

SAMPLE. TAFE NSW HLT51612 Diploma of Nursing (Enrolled/Division 2 Nursing) Course Clinical Record Book Workplace Component

SAMPLE. TAFE NSW HLT51612 Diploma of Nursing (Enrolled/Division 2 Nursing) Course Clinical Record Book Workplace Component HLT07 Health Training Package V5 TAFE NSW HLT51612 Diploma of Nursing (Enrolled/Division 2 Nursing) Course 14393 Student Name: Clinical Record Book Workplace Component Version 1.1 Ramsay Health Care Product