1. RN Skills Laboratory
Documentation
Week 3

2. Objectives Admission & Discharge Nursing History Charting
Care Planning
Reporting

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

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

5. 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

6. Nursing History Initial Information Chief Compliant (HPI) Medications
Identifying Data
Reliability
Chief Compliant (HPI)
Medications
Allergies
Past History
Medical, Surgical, Ob/Gyn, Psych

7. 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

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

9. HPI Essential elements to gathering data for present illness
Usually start 2 days before
Then day before
Then the current day

10. HPI PQRSTU Provocative or Palliative Quality or Quantity
Region or Radiation
Severity Scales
Timing
Understanding

11. HPI OLDCARTS Onset Location Duration Character
Aggravating/associated symptoms
Relieving factors
Temporal factors
Severity

12. 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)

13. Care Planning Approved WCU Care Plan Template Demographic information
Vital Signs
Admission Diagnosis
Diagnostic Procedures/Surgeries (with dates)
Discharge Referrals

14. Care Planning Erickson’s Developmental Stage
Socioeconomic/Cultural Orientation
Psychosocial Considerations
History of Present Illness
Past medical/surgical history (with dates)
Labs

15. 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

16. 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

17. 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

18. 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

19. 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

20. Change of Shift Report
Example of a change of shift report

21. Change of Shift Report Example of a narrative shift report
In room is John Doe
78 year old male
Patient of Dr. Jones
Admitted with FUO, currently being treated for sepsis
His problems areas are….

22. 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

23. Change of Shift Report References
Hays, M.M. (2003). The phenomenal shift report: A paradox. Journal for Nurses in Staff Development 19 (1),
Mosher, C. & Bontomasi, R. (1996). How to improve your shift report. American Journal of Nursing 96(8),