Name: __Julianne B. dela Cruz________________________________________________ Date: __Jan.

15, 2021_

Evaluator/Signature: __Clarence L. Nebres, MAN, RN_____________________________ Grade: _____________

CLINIC VISIT

Definition: Health care services provided on an ambulatory basis, rather than by admission to a hospital or other health-care facility. The services may be a part of a
hospital, augmenting its inpatient services, or may be provided at a free-standing facility.

Purpose:

1. Provides basic medical service such as vaccination

2. To confirm that program methodology are on the right tract
3. To assess health-care needs on available service for the low income, ____ community
4. To increase awareness and prevention of disease through patient education.

Equipment:

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 PERFORMED
ACTION RATIONALE REMARKS
YES NO

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I. Registration/Admission

1. Greet the client upon entry and establish rapport. To gain client’s confidence and trust.

2. Prepare the family record of new patients or Serves as baseline data or reference for future needs of patient
retrieve records of old clients.

3. Elicit and record the client’s chief complaint and To know client’s health concerns.
clinical history.

4. Perform physical examination on the client and Findings obtained from the physical examination helps to better
record accordingly. understand the patient’s current condition

II. Waiting Time To prioritize patients who came first.

1. Give priority numbers to clients

2. Implement the “first come, first served” policy To avoid cutting of lines and to give immediate care to patient in need

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 except for EMERGENCY/URGENT cases. of urgent care

III. Triaging

1. Manage program based cases. Prioritizing patient based on ____

2. Refer to all non-program based cases to the Severity conditioning must be seen by a physician immediately to avoid
physician. All other cases which has no potential complications on further damage.
danger, treatment/management is initiated by
the nurse and he/she decides to do his/her own
nursing diagnosis and then refer to the physician
for medical management.

3. Provide first aid treatment to emergency cases For continuity of care and prevent complication of condition
and refer when necessary to the next level of
care.

PERFORMED
PROCEDURE RATIONALE REMARKS
YES NO

IV. Clinical Evaluation To assure that the data obtained was accurate

1. Validate the clinical history and physical

examination.

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2. The nurse arrives at evidence-based
diagnosis and provides rational treatment
based on DOH programs.

a. Identify the patient’s program.

● To ensure accurate nursing education to be given.

b. Formulate/write the nursing diagnosis

and validate. ● To ensure that the care/diagnosis formulated is accurate and
according to patient’s need

c. Give/perform the nursing intervention.

d. Evaluate the intervention if it has

enabled the patient to achieve the ● For assurance of proper delivery of care
desired outcome.

e. Discuss important and applicable home

care instructions and the need for follow-
up visit as necessary.
● For continuity of care

3. Coordinate referral to next level of care So that the patient will receive the care he/she needs
(hospital, laboratory, city health office, etc.)
as necessary based on the needs and case of

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 the patient.

Learner’s Reflection: (What did you learn most of the activity? What is its impact Instructor’s Comments:
to you?)

In this activity I have learned the importance of documentation of information for

every patient and to validate every information given.

Reference:
Reyala, Jean P., et. al. 2000. Community Health Nursing Services in the Philippines. Community Health Nursing Section, NLPGN, Inc., Philippines.

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