RN Skills Laboratory
Documentation
Week 3
Objectives
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Admission & Discharge
Nursing History
Charting
Care Planning
Reporting
Admissions
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Advanced Directives
Clients Bill of Rights
Assessment by RN
Clearly identifiable by wrist band
Consent by adult guardians or DPOAs
Discharges
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Discharge instructions are given
Follow-up information is given
Education and handouts
Nursing History
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Essential elements of clinical care
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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
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Initial Information
– Identifying Data
– Reliability
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Chief Compliant (HPI)
Medications
Allergies
Past History
– Medical, Surgical, Ob/Gyn, Psych
Nursing History
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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
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Review of the systems (ROS)
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General
Skin
HEENT
Breasts
Respiratory
Cardiovascular, Peripheralvascular
Gastrointestinal
Urinary
Genital
Musculoskeletal
Psychiatric, Neurological
Hematologic, Endocrine
HPI
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Essential elements to gathering data for
present illness
Usually start 2 days before
Then day before
Then the current day
HPI
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PQRSTU
– Provocative or Palliative
– Quality or Quantity
– Region or Radiation
– Severity Scales
– Timing
– Understanding
HPI
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OLDCARTS
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Onset
Location
Duration
Character
Aggravating/associated symptoms
Relieving factors
Temporal factors
Severity
Charting Guidelines
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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
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Approved WCU Care Plan Template
Demographic information
Vital Signs
Admission Diagnosis
Diagnostic Procedures/Surgeries (with
dates)
Discharge Referrals
Care Planning
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Erickson’s Developmental Stage
Socioeconomic/Cultural Orientation
Psychosocial Considerations
History of Present Illness
Past medical/surgical history (with
dates)
Labs
Care Planning
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Pathophysiology (Need a med/surg text
book – no Tabers or Internet)
Collaborative Problems
– Prescriber’s Orders with rationale
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Medication list
Risk problem
Actual problem
Change of Shift Report
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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
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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
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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
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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
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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.