DCE Health History Assessment:
Complete the following in Shadow Health:
Orientation
Health History
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 4 Day 7 deadline.
Advanced Heath Assessment Documentation Tutorial
In each of the Shadow Health (SH) Assignments, you will be asked to complete a narrative note as part of the grading criteria. Narrative or progress notes are often a new skill. This document is provided to assist students in understanding how to write a narrative note. Shadow Health refers to these notes as Provider Notes.
Documentation of patient care is essential to quality and safety of care. Much of the clinical documentation is completed electronically using point and click tools to describe the patient condition (Lindo, et al., 2016). Often computer prompts fall short of fully describing the patient condition. Other situations such as lack of technology, electrical outages, system hacking, failure of equipment, and any number of situations which may interfere with normal electronic documentation may require a narrative nurses/progress note. Nurses must be able to clearly communicate patient information with everyone on the health care team to ensure quality and safety of care (Lindo, et al., 2016).
Documentation must be clear, paint a picture of the patient, and provide measurable concise information in a timely manner. The information communicated must be able to be understood by others and provide enough information to understand if a change has occurred in the patient condition and to clearly communicate all treatments, interventions, and therapies received by the patient and/or planned for the patient. Documentation also serves as a legal record of care (Lippincott Williams and Wilkins, 2007).
Documentation begins with subjective data/information. This is information the patient, family member, or caregiver may provide if the patient is unable to communicate which includes such data as the history of present illness (HPI), the past history- allergies, medications, medical surgical & social and the review of systems (ROS). Objective data/information includes the physical exam, observations and measurements obtained during the examination of the patient. Objective data also includes vital signs, laboratory and diagnostic results (Bates, 2017, pg.7)
Subjective vs. Objective Data-As you begin to acquire data from the patient interview and physical exam, it is important to remember the difference between subjective and objective information. Symptoms are the subjective concerns of what the patient tells you of their experience. Signs are the objective findings from your observations. (Bates, 2017, pg.6). Sequence of data is documented in the manner it is collected from the sequence of the examination. Physical examination follows a cephalocaudal sequence with the cardinal techniques of inspection, palpation percussion and auscultation (Bates, 2018)
Subjective information assists in understanding the patient condition and provides a basis upon which the nurse decides which body systems need to be assessed and which assessments need to be completed. Many of the assessments to be performed in the class are focused or problem based and focus on the assessment of a specific body system. The Comprehensive assessment is a complete health history and physical exam of most all body systems (Bates, 2017. Pg.5)
Once subjective and objective information are obtained and have been thoroughly considered an assessment/nursing diagnosis or medical diagnosis (physicians and advanced practice only) is identified. A plan of care will then be developed based on the nursing diagnoses. In the health assessment competencies, the primary focus is on gathering accurate subjective and objective data (Bates, 2017, pg.24)
Subjective data should be recorded using the patient’s own words and describing his/her feelings and experiences related to health. When interviewing the patient about a current issue or illness the seven attributes of a symptom need to be included in the documentation (Bates, 2017, pg.79)). The seven attributes
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