RN Skills Laboratory

Documentation

Week 3

Objectives

Admission & Discharge Nursing History Charting Care Planning Reporting

Admissions

Advanced Directives Clients Bill of Rights Assessment by RN Clearly identifiable by wrist band Consent by adult guardians or DPOAs

Discharges

Discharge instructions are given Follow-up information is given Education and handouts

Nursing History

Essential elements of clinical care– Empathic listening– Interviewing at all ages, moods, and backgrounds– Examination of different body systems– Clinical reasoning

Structure and purpose– Comprehensive vs Focused– Subjective vs objective

Nursing History

Initial Information– Identifying Data– Reliability

Chief Compliant (HPI) Medications Allergies Past History

– Medical, Surgical, Ob/Gyn, Psych

Nursing History

Family History Personal and Social History

– Substance use: smoking, alcohol, drugs– Occupation, Education– Interest, coping, Strengths, Fears– Marital status, Home situation– Exercise/diet, alternative health– Safety, spirituality

Nursing History

Review of the systems (ROS)– General– Skin– HEENT– Breasts– Respiratory– Cardiovascular, Peripheralvascular– Gastrointestinal– Urinary– Genital– Musculoskeletal– Psychiatric, Neurological– Hematologic, Endocrine

HPI

Essential elements to gathering data for present illness

Usually start 2 days before Then day before Then the current day

HPI

PQRSTU– Provocative or Palliative – Quality or Quantity– Region or Radiation– Severity Scales– Timing– Understanding

HPI

OLDCARTS– Onset– Location– Duration– Character– Aggravating/associated symptoms– Relieving factors– Temporal factors– Severity

Charting Guidelines

Procedure done Detailed description of the procedure Equipment used Characteristics of expected or unexpected

findings Patient/family response Care plan addressed Signature, designation (J. Kennett, SN)

Care Planning

Approved WCU Care Plan Template Demographic information Vital Signs Admission Diagnosis Diagnostic Procedures/Surgeries (with

dates) Discharge Referrals

Care Planning

Erickson’s Developmental Stage Socioeconomic/Cultural Orientation Psychosocial Considerations History of Present Illness Past medical/surgical history (with

dates) Labs

Care Planning

Pathophysiology (Need a med/surg text book – no Tabers or Internet)

Collaborative Problems– Prescriber’s Orders with rationale

Medication list Risk problem Actual problem

Change of Shift Report

There is little agreement on what makes a good report

Report is information and relationship exchange

Change of shift report is part of nursing culture that can improve patient care

Change of Shift Report

Be supported and therapeutic when communicating information

Provide information, actions and outcomes

Shift reports demonstrate the value of nursing actions, reflects nurses’ motivation and patient satisfaction

Change of Shift Report

Avoid negative criticism, praise for work well done

Not merely a mechanism of communication but activities prescribed by the physician and nursing activities

Do not give commentaries of staff or patient management

Change of Shift Report

Strategies in giving a good report– Incorporate into the plan of care– Site activities that have been done, and

those that have not been done– What are the discharge plans– Make sure your notes are documented in

the clinical record

Change of Shift Report

Example of a change of shift report

Change of Shift Report

Example of a narrative shift report In room 2203-2 is John Doe 78 year old male Patient of Dr. Jones Admitted with FUO, currently being

treated for sepsis His problems areas are….

Change of Shift Report

Alert/Oriented now B/P - stable the last 12 hours -110/70 at 1600 Fluids - receiving IV replacement and taking PO Output is improving 1800ml yesterday 2600ml

today - we need an UA C&S in the AM Social Services is talking about placement

because the family can not continue to care for him at home

Change of Shift Report

References

Hays, M.M. (2003). The phenomenal shift report: A paradox. Journal for Nurses in Staff Development 19 (1), 25-33.

Mosher, C. & Bontomasi, R. (1996). How to improve your shift report. American Journal of Nursing 96(8), 32-34.