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

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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 1.1 Ramsay Health Care Product Code 5744

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

3 Contact Details Passport Sized Photo here: Student Enrolled Nurse details 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: Hospital name: Hospital details... Hospital address:... Workplace contact name:... Designation: Phone Number... Workplace contact phone number:... Head teacher s name: Phone Number 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: Contact Details... 3 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 SECTION THREE: SUMMARY OF CLINICAL SKILLS OBSERVED and PRACTISED IN THE WORKPLACE Summary of Workplace Holistic Assessment Events: 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 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 CLINICAL SKILL ASSESSMENT FORMS Page 4 of 84

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 Screening. 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. You should also review the Code of Ethics and the Code for Professional Conduct for nurses that are both available on the following website. Clinical Placement This Clinical Record Book contains Clinical Objectives for completion during your clinical placements. Your TAFE NSW 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 if lost, you contact your head teacher and present a Statutory Declaration to obtain a replacement book (this may incur a cost). Page 5 of 84

6 Role of the TAFE NSW Facilitator The TAFE NSW Facilitator will meet with you during professional experience placement. The role of the TAFE NSW Facilitator is to liaise with health facility staff and assist you to achieve the most from your professional experience. The TAFE NSW 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 Facilitator will liaise with health care facility staff to collect information regarding your clinical performance and attributes required for employability. Feedback will be obtained about punctuality, communication skills, and student s ability to work as a member of a team, your ability to work within their scope of practice, professionalism and general work ethics. 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 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. Students are only permitted three attempts to achieve competency with assessments. An action plan will be developed and documented after the second attempt before the student attends their third assessment attempt. It would be appropriate to consider an alternate assessor for the third assessment attempt if the one assessor had undertaken the first two unsuccessful assessments. The clinical coordinator is to be notified of the failed second assessment and they will notify the TAFE NSW head teacher if the student gives you cause for concern during their clinical placement. If client safety is ever an issue the registered nurse is to contact the clinical coordinator and the actions as outlined on page 8 will be implemented. 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 each TAFE NSW institute] As part of this course you are required to undertake and be observed performing the following: Page 6 of 84

7 1. Holistic assessment The Holistic Assessment will be undertaken several times in the professional experience environment. This assessment is to assess your interaction with clients, your communication skills and application of clinical skills. The aim of the Holistic assessment is to gain feedback on the application of skills in the clinical context. 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 module & achievement of employability skills. 2. Observation of skills You will be required to be observed competently performing the 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. Cardiopulmonary resuscitation will not be reflected in this list. 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 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 Facilitator or health care facility staff member. Your TAFE NSW 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

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 Immediate notification to on incident and discuss appropriate body and student outcomes with TAFE removed from client contact or Facilitator care facility Documentation of incident in student s file Documentation of incident, plan of action, process, Student returned to simulated environment timeframes and outcomes Revision of client safety issues recorded by TAFE Facilitator in student s file Revision and supervised practice of required components Agreed plan of action, process, required outcomes and timeframes documented Assessment in simulated environment and evaluation Student to sign and keep a of risk potential 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 health frames set 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 Page 9 of 84

10 SECTION TWO: NATIONAL COMPETENCY STANDARDS The Australian Nursing and Midwifery Council (2002) National Standards for the Enrolled Nurse. The Australian Nursing and Midwifery Council (ANMC) National 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. unit 1 unit 2 unit 3 unit 4 unit 5 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. Demonstrated YES/ NO Contributes to the formulation of care plans in collaboration with the registered nurse, individuals and groups. Head Teacher /Course Coordinator signature unit 7 unit 8 unit 9 unit 10 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 within the scope of enrolled nursing practice. 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. Page 10 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 2 Ramsay Health Care Product