Simulation Design Template
(revised May 2019)
(name of patient) Simulation
File Name: Student Level: Guided Reflection Time: Twice the amount of time that the simulation runs. Location for Reflection:
Date: Discipline: Nursing Expected Simulation Run Time: Location: Today's Date::
Brief Description of Client
Name:
Date of Birth:
Gender: Age: Weight: Height:
Race: Religion:
Major Support: Support Phone:
Allergies: Immunizations:
Attending Provider/Team:
Past Medical History:
History of Present Illness:
Social History:
Primary Medical Diagnosis:
Surgeries/Procedures & Dates: