Perioperative Nursing

Clinical Observation Log

Student: _____________________________________________ Clinical Site: _________________________ Date: _____________

Complete each section with the information requested. When completing the first section, please
include the procedures you observed/participated in and the activities you performed during the
procedure.

The clinical reflection log is due XXXX.

Date All Procedures and Activities Associated with Each Procedure

Comment on two of the following QSEN competencies: Teamwork and Collaboration, Evidence-Based
Practice, Quality, Safety, Informatics, Patient-Centered Care.

Competency Observations/Discussion/Action that Can Be Taken

Pick one patient and identify all nursing diagnoses for that patient and list at least three
interventions for each diagnosis.

Date: _______________ Patient Initials: _____________________________

Procedure: ______________________________________________________________________________________________________

Describe Indication for Procedure: ____________________________________________________________________________

____________________________________________________________________________________________________________________

Nursing Diagnoses Interventions (Minimum 3), Include Actual/Observed

(Minimum 3) Interventions Performed by the Student of the Outcome
Health Care Team Member

May 2017
Adapted with permission from Case Western Reserve University