Nursing Student Clinical Paperwork: What to Expect and How to Prepare
Clinical paperwork is how instructors see your reasoning. It can feel like a lot, but most of it follows a few repeating patterns.
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Typical paperwork
- Pre-clinical preparation sheets on your assigned patient
- Care plans or concept maps
- Medication research for each drug the patient takes
- Skills checklists signed off by supervisors
- Daily logs and reflective journals
Protect patient privacy
Use initials or an assigned ID. Never write names, dates of birth, record numbers or other identifiers. In the US, the HIPAA Privacy Rule applies to how you handle this information; your school will also have its own rules.
Prepare efficiently
Research the main diagnosis and medications the evening before, write your priority problems, and bring specific questions. Afterwards, write your reflection while the shift is fresh.