Louisiana State Board of Nursing
17373 Perkins Road
Baton Rouge, LA 70810
Phone: (225) 755-7500
www.lsbn.state.la.us
Clinical Nursing Student Medical-Mental Condition
Diagnostician / Treating Provider Form
Student Consent to Disclosure of Medical Information and Records
I, ___________________________________ do hereby authorize all of my health care providers to disclose and
(PRINT NAME)
furnish any and all information, records, and opinions, any reports or summaries thereof, whether in electronic form or otherwise,
relating to my evaluation, diagnosis, treatment and prognosis by or under the care of the health care provider, to the Louisiana
State Board of Nursing, and any representatives thereof (collectively referred to as the "Board"), for the purpose of permitting the
Board to be initially and periodically advised of my diagnosis, treatment and prognosis for any condition, including but not
limited to my disability which may impair my capacity my ability to participate in clinical nursing education, test, or practice
nursing with reasonable skill and safety to patients or to myself. __________________________________ (signature and date)
Diagnosis Information
Date of initial diagnosis: ______________________________
Diagnosis Code (DSM or ICD-9): ___________________________________________
Diagnosis: ______________________________________________________________
Provide summary of current treatment plan including all medications (name and dosage) prescribed for
treatment of the student’s diagnosis: (add additional sheet if necessary)
___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Indicate which, if any, of the following major life activities are adversely affected by the student’s
diagnosis.
Walking Seeing Hearing Speaking
Breathing Learning Thinking Working
Caring for one’s self Performing manual tasks
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Does this diagnosis affect the student’s YES NO
ability to safely practice nursing?
If Yes, provide explanation:_________________________________________________
________________________________________________________________________
________________________________________________________________________
Indicate whether the student is able to meet the following cognitive, sensory, affective and psychomotor
performance requirements by indicating “Yes” or “No” next to each technical standard.
Issue
Requirement
Example
YES NO
Critical Thinking
Critical-thinking ability sufficient for
clinical judgment
Identify cause/effect relationships in
clinical situations, develop nursing
care plans
YES NO
Interpersonal
Interpersonal abilities sufficient for
interaction with individuals, families,
and groups from various social,
emotional, cultural, and intellectual
backgrounds
Establish rapport with
patients/clients and colleagues, and
respond appropriately to stressful
situations
YES NO
Communication
Communication abilities sufficient for
verbal and written interaction with others
Explain treatment procedures,
initiate health teaching, and
document and interpret nursing
actions and patient/client responses
YES NO
Mobility
Physical abilities sufficient for
movement from room to room and in
small spaces
Move around in patient's room, work
spaces and treatment areas;
administer cardiopulmonary
procedures
YES NO
Motor Skills
Gross and fine motor abilities sufficient
for providing safe, effective nursing care
Calibrate and use equipment;
position patients/clients
YES NO
Hearing
Auditory ability sufficient for monitoring
and assessing health needs
Hear monitor alarm, emergency
signals, auscultatory sounds and
cries
YES NO
Visual
Visual ability sufficient for observation
and assessment necessary in nursing care
Observe patient/client responses,
including color changes
YES NO
Tactile
Tactile ability sufficient for physical
assessment
Perform palpation, functions of
physical examination and/or those
related to therapeutic intervention
(such as insertion of a catheter)
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Diagnostician / Treating Provider Information
Provider
Name: ______________________________ Title: ____________________
(Please print or type)
Address: _______________________________________________________
_______________________________________________________
Phone: _______________________________________________________
Type of Professional License: ____________________________________________
License Number: ________________________
State of Licensure: _______________________
Specialty Certification/Qualifications: _______________________________________
______________________________________ ___________________
Signature Date
STU 03 – 8/6/2013, 6/24/14, 1/5/15, 5/11/15 1/22/16, 7/25/16 PAD
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