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: