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1220W - Health Assessment and Promotion > Week 3 - Class 2 (Health History & Documentation) > Flashcards

Week 3 - Class 2 (Health History & Documentation) Flashcards

1
Q

What are types of data sources?

- Define and explain each

A

1) Primary
- The Patient
- Ex. For children parents act as the primary data source or someone who is mentally impaired

2) Secondary
- Charts and family members

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2
Q

Is is okay to have a translator as the source of primary data?

What about an interpreter? What type of data source is it?

A

Yes it is primary

  • They are literally translating verbatim
  • They are not changing the language

Interpreter is trying to maintain the sentiment but in a new language

  • Things may be distorted, changed, miscommunicated, or lost
  • Secondary
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3
Q

What is a historian? What can the nurse decide?

A

A person who is giving you info/story/describing events, and they may be reliable or unreliable as determined by the practitioner asking questions
- That a history is not going to be taken until a reliable person shows up

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4
Q

What are unreliable or inaccurate historians?

A
  • Intoxication
  • Delirium
  • Cognitive decline
  • ESL
  • Acute illness
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5
Q

What are cues that a person will not be able to provide a reliable history?

A
  • Unable to follow conversation
  • Inappropriate/confused answers
  • Decreased LOC
  • Speech difficulties
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6
Q

What can you do as a nurse when you have an unreliable historian?

A

1) Identify the person who provides the info
2) Note discrepancies

3) Identify other sources to confirm the history
- You can requisition old charts to get more info
- You can gather data from multiple sources to piece together necessary info
- Come to terms with that you may only have some of the data you need

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7
Q

What are the three types of health histories?

- Explain each

A

1) Comprehensive: Review of systems, family history, surgical/medical history
- Ex. Annual physical, major surgery, etc.

2) Focused: Based on presenting symptoms/problem and associated findings - may need bits and pieces from comprehensive, but pick and choose based on clinical judgment
- Ex. For example, a patient recovering after some sort of trauma may mention some new onset nausea to you part way through the day. This would be an opportunity for you to collect a focused history on this new complaint, and then see if there are any nursing interventions that might be suitable.

3) Emergent: Most pertinent info needed at the time, usually at the same time as interventions
- Ex. Motor vehicle accident - Allergies, blood type, where does it hurt? Things you need at that exact moment in time

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8
Q

What are two types of data used when gathering data?

A

Subjective data: Stated by client (symptom)

Objective data: Observed/measured by the nurse (signs)

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9
Q

Are the following subjective or objective data?

  • Nausea
  • Vomiting
  • Shortness of Breath
  • Cough
  • Reports from family members
  • Balance/coordination
  • Pain
  • Heart rate
  • Water intake
  • Weight
A

Nausea - Subjective

Vomiting - Both

  • PT could report
  • Nurse could observe

Shortness of Breath
- Subjective

Cough - Both

  • PT could report
  • Nurse could observe

Reports from family members - Subjective

Balance/coordination - Both

  • PT could report
  • Nurse could observe

Pain - Subjective

Heart rate - Objective

Water intake - Objective

  • As long as nurse is measuring
  • If PT reports = subjective

Weight - Objective
- If nurse weighed PT

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10
Q

When gathering a health history of a PT, what should a nurse ask about?
- Comprehensive perspective

A

1) Lead with why the PT is seeking care
- “What brings you in today?”

2) Past history
- Past diagnosis/medical problem, surgeries, etc.

3) Family history
- First degree relatives
- I.e. Parents, siblings

4) Current medications
- OTC, vitamins, supplements, etc.

5) Allergies
- Medication, food, environmental

6) Lifestyle
- Alcohol, smoking, diet, exercise, caffeine, sleep, substance/drug use

7) Social, Culture, and Spiritual considerations
- Family, living arrangements, work status, stressors

8) Human violence
- Use discretion

9) Sexual history and orientation
- Use discretion

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11
Q

Ae nurses typically responsible for gathering comprehensive histories?

A

Generalist nurses are not typically responsible for gathering comprehensive histories, rather, they pick and choose form the comprehensive list using their clinical judgment

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12
Q

How do you get a good health history from a PT?

A

OEstablishing rapport and building even a beginning level of trust around sensitive topics allows for greater opportunity to get a good history – there’s some finesse to this.

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13
Q

How do you ask questions when gathering a health history?

A

OLDCARTSS

O: Onset
- When did it start?

L: Location
- Where is it located? Does it radiate?

D: Duration
- How long have you have it?

C: Character
- Can you describe it?

A: Aggravating Factors
- What makes it worse?

R: Relieving Factors
- What makes it better?

T: Timing

  • When does the pain happen?
  • Is it constant or does it come and go?

S: Severity

  • Pain out of 10
  • Worst pain?
  • Where would you score it?

S: Self-Perception
- What do you think is happening or causing this?

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14
Q

Do you have to follow OLDCARTSS in direct order?

A

Try to remind yourself that OLDCARTSS is simply a method of remembering different aspects of data collection - It isn’t structured in any sort of common way, and it is meant to be treated as flexible and adaptable to the situation

  • It is not meant to stifle your clinical judgment
  • Nurses can ask ANY QUESTION they want if they deem it appropriate
  • If there is therapeutic purpose, then anything goes
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15
Q

What else needs to be added when using OLDCARTSS?

A
  • At some point, you need to add medications, allergies, and past medical history to the questions
  • Add anything else that could be important, like associated symptoms (if they say they’ve been vomiting, ask if they’ve also been experiencing diarrhea, for example)
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16
Q

What should you realize about OLDCARTSS questions?

A

Think about your questions, don’t just memorize them!

- Ask the useful questions

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17
Q

What is important during uncomfortable topics?

  • How to deal with it?
  • What should you pay attention to?
  • What should you watch out for?
A

Think about who is really uncomfortable, you or the patient!

  • Ideally you come into the situation prepared and arranged the data collection to suit the relationship
  • PT cues and your own cues
  • Your own body language (i.e. face, body, tone, language, manner)
18
Q

How do you approach an uncomfortable situation?

A

Be straightforward, open, and comfortable - you have done what you can

19
Q

If a patient has questions for you that seem to make them uncomfortable, how can the nurse handle it?

A
  • Supportive reassurance
  • Non judgmental attitude
  • Open, caring, empathetic
20
Q

If a nurse introduces topics that could be interpreted by patient as uncomfortable?

A

Try to establish:

  • Rapport
  • Non-judgmental approaches
  • Timing
  • Trust
21
Q

Using Clinical Judgement -Example #1:

Client presents with a cough – what other questions will influence your clinical reasoning

A

When patients report a cough, your want to find out whether the cough is dry (unproductive cough) or whether there is mucous (productive caught)

  • If the cough is productive, you want to find out what they are coughing up (characteristics of the sputum), colour, amount, frequency, consistency, presence of blood
  • Think back to the example from 1225 when you were sticking the cards to the white board to create a note
  • The productive cough, the associated symptoms, and the appearance of the sputum helped us to form a clinical judgment about what we thought was important and what we though was less important
  • In this case, the characteristics of the cough, such as productive or unproductive, meant something to us
  • In 1225, the example lead us toward possible bacterial infection while a dry cough may have led us more to a viral infection
22
Q

Using Clinical Judgement - Example #2:

Female client presents with lower abdominal pain? What other systems might you need ask questions about?

A

Lower abdominal pain could mean several things

  • How old is our female client? If she is still in child-bearing years I would have some questions to pursue there
  • If she is post menopausal, I might rule some things out. - Could the complaint be bowel related? Perhaps I would ask about bowel patterns, or perhaps urinary changes
23
Q

Using Clinical Judgement - Example #3:

Client presents with back pain. What demographic data changes the potential causative agent?

A

Demographic data such as sex and age could change what I ask about

  • Is the patient working or retired?
  • We know that men tend to be the ones working the harder manual labour jobs and are therefore at increased risk for injury, if the back pain is related to injury, from what type of activity? Work?
  • Where is the pain in the back, is it stress related?
24
Q

What is documentation important for?

A
  • Communication about client‘s health status and needs to all members of the health care team
  • Communication of a client centred plan of care to other nurses
  • Communication of changes in a client’s condition or situation
  • Communication of a client’s educational/information needs
25
Q

What is documentation?

A

It is a record and a timeline

  • Refers to what exact nursing care is provided to a PT (i.e. what was done and what was not done)
  • It keeps everyone current, including the client, and ensures continuity of care
26
Q

What does documentation demonstrate?

A

Demonstrates that the nurse has applied the nursing knowledge, skill and judgment required by professional standards & regulations

27
Q

Is a documentation a legal record?

A

All documentation, whether flow sheet or long-form note, is a legal record

  • It is in everyone’s best interest that documentation be complete, accurate, timely, and professional
  • Can be brought into court
28
Q

What are 3 CNO Documentation Standards? Explain why they are important:

A

“Supporting nurses’ development of information and knowledge management competencies, and designing continual quality improvement activities related to effective documentation.”

  • Why the reference to quality improvement activities?
  • This is in reference to one of nursing’s core values which is lifelong learning
  • There is always opportunity to become better at a nursing skill, even if (and for some, especially if: you’ve been doing it a certain way for a very long time

“Developing performance management processes that provide opportunities to improve documentation.”

  • The best practice council does audits now and then of charts in the hospital setting to gather data about common practices amongst nurses and on particular units, and to gather data about gaps in practice and ways in which those gaps might be addressed through continued learning
  • You are never a finished product as a nurse

“Providing adequate time to document appropriately and review prior documentation.”

  • Taking the time on your shift to documents appropriately and in keeping with standards of practice requires planning
  • You have to make time for it just like any other activity
  • It shouldn’t be left to the end, and it shouldn’t be rushed
  • It’s important that documentation actually does what it is supposed to do
29
Q

What should documents BE?

What should documents INCLUDE?

A

BE:

  • Factual
  • Accurate
  • Concise
  • Relevant
  • Complete
  • Organized

INCLUDE:

  • Proper grammar
  • Spelling
  • Punctuation
  • Professional language/terminology
30
Q

What are the legal guidelines for documentation?

A
  • Do not erase or use white out (Why?)
  • Record pertinent facts
  • Do not leave blank spaces in the note (Why?)
  • Write legibly & in ink
  • Chart only for yourself (Except when?)
  • Avoid using generalized phrases
  • Begin each entry with date, time.
  • End each entry with signature & designation (WCTF-1 )
  • Be considerate of language used (i.e. correct terminology)
31
Q

What is true about documentation errors?

A

Your errors need to be legible/trackable (if electronic) after your correct them

  • A single line to stroke through, write “err” with your initials, and continue writing
  • No scribbling, no squeezing words in above the line, legible
32
Q

Is punctuation important in documentation?

What should you do?

A

Yes!
- It can change the meaning of the documentation

Organize your thoughts!
- Would another person get what you mean?

33
Q

What are three things you should avoid to remain factual during documentation?

What should you be cautious of?

A

1) Avoid words such as “seems” or “appears”
- This suggests an opinion rather than a fact

2) Avoid vague words such as “good” or “some”

3) Avoid giving an opinion, such as “the client is progressing well”
- This is an interpretation and won’t mean the same thing to all caregivers

  • Be cautious of the word ‘normal’
  • It can be open to too much interpretation
34
Q

What is subjective interpretation? Why should you avoid this?

A

“Subjective interpretation” is what is happening when the words “seems” or “appears” or “because” sneak into your writing
- It’s just a matter of rephrasing to keep it bias-free and factual for the reader

35
Q

How can you be more specific in documenting the following examples?

1) Continue to monitor
2) RTC if signs and symptoms worsen, or do not improve
3) Stable

A

1) Monitor q 2 hours and prn.
2) RTC immediately if increasing cough, dyspnea, fever, or if no resolution of symptoms in 3 days
3) Vital signs are within normal limits, patient is resting, reporting 2/10 on pain scale

36
Q

What does SOAP stand for?

A

SOAP

S: Subjective

O: Objective

A: Analysis

P: Plan

37
Q

What should SOAP documentation look and sound like?

A

It should look like a paragraph and sound like point-form notes

38
Q

What are important features of a SOAP document?

A

1) Date and time
- Military time

2) PT name
3) Physician
4) Title

5) Sections of SOAP
- For clarity and standardization

6) Analysis is always phrased “ (problem) related to (cause/possible cause).
- Cause can be unknown (i.e. unknown origin or unknown etiology)

39
Q

When you document in SOAP how do you document time?

A
  • Military clock

- Round to nearest ‘5

40
Q

Review Lecture:

  • Proper Documentation Example
  • Improper Documentation Example
A

Proper:

  • Concise points
  • Problem related to cause
  • Signature correct

Improper

  • Lengthy sentences, very wordy
  • Objective Data: Some irrelevant info, just make a quick comment and be specific (combine pieces of info)
  • Analysis is not worded properly (i.e. problem related to cause)
  • Plan: Weak, more specific, do more for the nurses working after you
  • Signature in wrong place
41
Q

Review Lecture - Signatures:

Example #1: Room on the line for signature?

Example #2: Little room on line for signature?

Example #3: No room on the line for signature?

A

1) As in the previous slide, if I don’t fill up my last line, and I determine that there is room for my signature, I can sign on the right and fill in any space with a line.
2) If I haven’t quite filled up the line, but there isn’t enough room for me to apply my signature without it being all squished and illegible, then I can do this.
3) If I go all the way to the end of the line with my writing leaving no room for anything else, I drop down to the next line and sign.

1220W - Health Assessment and Promotion (9 decks)

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