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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 of a symptom would be asked for any positive response during the health history (HH) and review of systems (ROS). Here is a list of the attirbutes and a few sample questions for a patient with complains of abdominal pain (Bates, 2017, pg.79)

· Location: “Where does it hurt?” “Please point to the area of pain.”

· Quality: “How would you describe the pain?” “Is it sharp pain?” “Dull pain?”

· Quantity or Severity: “On a scale of 0-10, 0 being no pain and 10 being the worst pain ever, what is your level of pain?” “How has the pain impacted your daily routine?”

· Timing: “When does the pain occur?” “How long does it last?” “Approximately how long after you have eaten does the pain begin?” ”Does the pain radiate?” “If yes, where does it radiate?”

· Onset or Setting in which it occurs: “What were you doing when the pain began?”

· Aggravating or Relieving Factors: “Is the pain worse after eating certain foods?” “What makes the pain better?”

· Associated Factors: “Do you have any nausea or vomiting?” “Any diarrhea?” “Any constipation?”

Another way to remember what to ask the patient is to use the mnemonic OLDCARTS or OPQRST (Bates, 2017. p.79)

O: Onset

L: Location

D: Duration of symptoms

C: Character

A: Aggravating/Alleviating Factors

R: Radiation

T: Timing

S: Severity

OR

O: Onset

P: Provocative or Palliative

Q: Quality or Quantity

R: Region or Radiation

S: Site

T: Timing

When documenting the ROS it is necessary to document each condition or item asked about because others will be reading the notes and relying on the information provided. If information is incomplete or inaccurate patient safety and quality of care may be affected. Documentation of pertinent negatives should be specifically described. Do not overgeneralize by using terms such as “WNL”, or neurologic exam negative” as this does not convey what exactly was assessed subjectively and/or objectively (Bates, 2018, p. 38)

ROS (Subjective) Documentation Example:

Review the following ROS areas and the associated documentation and note the quality of the information provided for each system.

· Skin: Denies any rashes or changes to skin

· Head: No problems with head or headaches.

· Ears: Positive for fullness feeling in bilateral ears for past 2 days, denies changes in hearing, pain in ears or any drainage.

· Eyes: No problems, says they are normal.

Skin and ears are documented correctly. The skin description relays what items were subjectively asked of the patient. The ears ROS also includes pertinent positive with further information and pertinent negatives.

Head and eyes are not documented correctly. There is not a description of the items subjectively asked and is an incomplete picture.

(Bates, 2017, pg. 32)

Assessment (Objective) Documentation Example:

Skin: Uniform in color, tan, warm, dry, intact. Turgor good, skin returns immediately when released. Scattered flat small macules on face around nose. On back of left shoulder 4mm, symmetrical, smooth borders, dark brown, evenly colored, slightly raised nevus, without tenderness or discharge. Well healed pale scar 3 cm right forearm. Left wrist approximately 1 cm area around the circumference of the wrist pruritic papules and vesicles with an erythematous base. Silver colored striae around lower outer quadrants of abdomen and hips.

· Head: Shape okay.

· Eyes: Eye color brown. brows, lids, and lashes symmetric, right brow ridge piercing with intact silver hoop, no redness, tenderness, or discharge; lacrimal ducts pink and open without discharge. Conjunctiva clear, sclera white, moist, and clear, no lesions or redness, no ptosis, lid lag, discharge or crusting. Snellen vision assessment 20/20 in each eye with corrective lenses. EOMs intact, no nystagmus, PERRLA

· Ears: TM with good cone of light, pearly gray appearance, canal clear of wax bilaterally, no edema or drainage present. Auditory acuity present bilaterally to whispered voice.

Skin is documented very complete and concise a picture of the patient is evolving and measurable assessment data is provided. Complete description of the rash on the left wrist provides a measurable concise picture. A mole was noted and documentation included the ABCDE of the mole. It is important to describe both normal and abnormal findings in a measurable manner. The text offers examples of how to provide measurable information for many assessment findings such as tonsils, pulses, reflexes, and strength (Bates, 2017, pg. 33)

The documentation for head is less measurable. How is one to know what “shape okay” is for this patient?

The documentation for the eyes is very thorough and concise. Measurable terms are used and a description of the patient’s eyes is provided.

The documentation for the ears is also very concise and thorough. Measurable terminology is used and a description is provided.

Some of the Shadow Health (SH) exams focus on one body system such as Cardiac. In this situation focus on pertinent questions related to the ROS and physical assessment for cardiac and any associated body systems. In the case of cardiac, peripheral vascular and respiratory would be additional systems to assess.

When completing the assessments in SH use the textbook as a guide. Open to the appropriate chapter and follow along to ensure all aspects of the assessment are covered for both subjective and objective assessment areas. Document carefully for each assessment area keeping in mind the differences between subjective and objective information and ensuring measurable concise information is recorded.

Subjective and objective information is separated and each body system is used as a heading for easier retrieval of information. When information is disorganized it is difficult to know which is the information provided by the patient and which is the objective clinical assessment data. In an emergency retrieval of information must be done quickly. Well organized and written notes allow for timely retrieval (Lindo et al., 2016).

References

Bickley, L. S. (2017). Bates Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins: Philadelphia, PA.  

Lindo, J., Stennett, R., Stephenson-Wilson, K., Barrett, K.A., Bunnaman, D., Anderson-Johnson, P., Waugh-Brown, V., and Wint, Y. (2016). An audit of nursing documentation at three public hospitals in Jamaica. Journal of Nursing Scholarship, 48(5), 508-516.

Lippincott Williams & Wilkins (2007). Charting: An incredibly easy pocket guide. Ambler, PA: Author.

© 2019 Walden University Page 1 of 5

Name:

Section:

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Skin:

Hematologic:

Endocrine:

© 2021 Walden University Page 1 of 1

Name:

Health History

Identifying Data

Tina Jones

Open this PDF and type your narrative-style documentation for each section into the corresponding dialogue
box below. When you are ready to submit your documentation, ‘Save As’ a new PDF and enter your name.
Upload the PDF with your name into Blackboard.

Tina Jones, 28 years old

Date of Birth: 2/17/1982

African American

Female

Document: Provider Notes – NURS 6512

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General Survey

Chief Complaint

1. Redness around the scrape
2. Pain started as 5 or 6, but now a 10/10 with weight bearing
3. Pain is worse during weight bearing, “throbbing and sharp” feeling, Tramadol effective

“I got this scrape on my foot a while ago”

Describes pain as “this pain is killing me”

Scrape happened “1 week ago,” but pain is “worse in the last few days.”

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History of Present Illness

29-year-old AA female presents to clinic for complaints of aching pain 7/10 to bottom of right foot.
Pain started 1 week ago after she scraped her foot, and pain has worsened in the “last few days.”
She describes pain as “this pain is killing me.” New onset, 2 days ago of “white or off-white”
purulent drainage, without odor. Aggravating symptoms are weight bearing resulting in increased
pain 10/10. Relieving factors are the use of Tramadol and non-weight bearing activities. She is
cleansing wound with hydrogen peroxide, and changing the bandage twice a day, every morning
and night. Current dressing is moderately soiled, SS drainage observed seeping through dressing.
She complains of a fever last night with oral temp of 102 degrees Fahrenheit.

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Medications

1. Tramadol 50 mg: She is taking 2 tabs three times a day (morning, noon, and night). Last
dose taken this morning.

2. Proventil (Albuterol Sulfate) Inhaler 90 mcg: 2 puffs. Needs 2-3 times/week and has been
needing up to 3 puffs lately. Last date taken unknown.

3. Takes Ibuprofen occasionally for cramps.
4. Denies vitamins or supplement use.

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Allergies

Medical History

1. Cats: Sneezing, itchy eyes, wheezing, and asthma exacerbation
2. Penicillin: Rashes and Hives
3. Denies any food allergies
4. Denies latex allergy

1. Asthma, well controlled: triggers are mostly cats, but also dust and running up the steps.
Asthma attacks with feelings of chest and throat tightness, wheezing, and feelings of “not
enough air.” Last asthma attack was in high school.

2. Diabetes Mellitus Type 2, poorly controlled. Diagnosed at 24 years of age
3. Last Hospitalization was at age 16

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Health Maintenance

1. Last A1C unknown saying, “I was probably a kid.” BS today is 238
2. Infrequent blood glucose monitoring
3. Last took Metformin 3 years ago after taking for 1 year. Dose unknown.
4. Last seen provider 3 years ago, when 1st diagnosed with Diabetes Type II.
5. Drinks diet sodas, avoids sweets, and denies adding salt to meals
6. Eats 3 meals a day, carbohydrate intake unknown
7. Education to be provided on Diabetes management.
8. Immunizations are up to date
9. Tetanus vaccination received in the last year
10. Denies ever receiving the Influenza vaccination

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Family History

1. Father: Diabetes Type II and HTN. Died in Car accident last year after car hydroplaned in
rainy weather.

2. Mother: HTN, High Cholesterol. Mother was depressed after spouse’s death.
3. 1 Sister with Asthma
4. Brother without any health concerns
5. (P) Grandfather: Type II Diabetes, HTN. Died of Colon Cancer
6. (P) Grandmother: High Cholesterol. Taking BP meds for HTN. Currently lives alone
7. (M) Grandfather: HTN, MI. Died in car accident with patient was a child
8. (M) Grandmother died 5 years ago, post CVA. She had High Cholesterol and HTN
9. Paternal Uncle: Alcoholism
10. Family History of Obesity

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Social History

Review of Systems

1. Single, never married, no children,
2. Resides with mother and sister
3. Currently in college to obtain Bachelor’s in Accounting
4. Denies any financial difficulties to pay for medications or treatments.
5. Baptist, highly involved with family church
6. Denies tobacco use and denies vaping
7. Last smoke marijuana at age 20 or 21
8. “A few” Alcoholic beverages 1-2 times/week
9. Identifies supportive network as several family members
10. She grieved appropriately after father’s death

Subjective

? General: Fever last night of 102 degrees orally. Unintentional weight loss of 10 lbs in last month.
? HEENT: Has occasional headaches. Has blurry vision, but does not wear corrective lenses. Last eye

exam was during childhood. Runny nose is infrequent. Denies difficulty with swallowing.
? Respiratory: Denies cough. Denies shortness of breath. Last asthma exacerbation wsa 3 days ago.
? Cardiovascular/Peripheral Vascular: Denies chest pain or discomfort. Denies any palpitations or

arrythmias. Denies hx of murmur.
? Gastrointestinal: Denies N/V. Denies any abdominal pain. Denies diarrhea or loose stools.
? Genitourinary: Increase in urination
? Musculoskeletal: Denies arthralgia or myalgia. Denies any pain or discomfort with movement to

extremities. Denies history of trauma or fractures.
? Psychiatric: Denies suicidal or homicidal ideation. Denies anxiety or depressive symptoms
? Neurological: Denies paresthesia, headaches, or dizziness.. Denies problems with gait or coordination.

Denies any falls or seizure activity.
? Skin: Has a wound to bottom of right foot with aching pain. White or off-white purulent drainage

present without odor.
? Hematologic: Denies any problems with bleeding. Denies any problems with clotting. Denies hx of any

blood clots.
? Endocrine: Increase thirst and increased in water intake.

Objective

? Vital Signs: 142/82-86-19-99%. Oral temp 101.F Wt: 90 kg. BMI 31

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Running head: TINA JONES HEALTH HISTORY NARRATIVE

Tina Jones Health History Narrative

Anna M. Medina

Professor Deborah Mathias

NUR 3700: Nursing Health Assessment

Metropolitan State University of Denver

TINA JONES HEALTH HISTORY NARRATIVE

Introduction

A complete health history based upon work in Shadow Health was completed on Tina

Jones, a twenty-eight year old woman. Ms. Jones came in through the emergency department for

an injury to her right foot. Utilizing interviewing and clinical skills, and clinical reasoning skills,

the ability to perform a health history was successful.

Health History

Finding Data and Reliability

Ms. Tina Jones is a pleasant twenty-eight year old African American woman. She is

seated upright in her hospital bed. She was admitted for further evaluations of her right foot

injury. She is the primary source of the history. She offers information freely. Her speech is

clear and coherent. She maintains good contact throughout the interview.

General Evaluation

Ms. Jones is alert and oriented. She appears to be in pain. She is well nourished. She is

well groomed, dressed appropriately, has good hygiene, and interacts appropriately.

Chief Complaint

Ms. Jones’s chief complaint is that “I hurt my right foot one week ago” They said I

needed to get admitted to the hospital.

History of Present Illness

Ms. Jones has an open wound to her right foot located on the plantar surface. She has

asthma and type II diabetes. She injured her foot by scraping the bottom of a stepping stool. She

states that she was barefoot at the time of the injury. She states that her current pain is 7/10, and

last received medication in the emergency department that seems to be helping. She states that

her pain is made worse when she stands, and is unable to bear weight on her right foot. She does

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TINA JONES HEALTH HISTORY NARRATIVE

not monitor her blood sugar and does not take any medications to control her diabetes. She

reports that her asthma is triggered when exposed to cats, dust, or running upstairs. Her blood

pressure is also high as well as being febrile with a temperature of 39.1 C.

Medications

She uses a Proventil (Albuterol 90mcg/spray MDI) inhaler for asthma. She last used her

inhaler three days ago. Ms. Jones takes two pills of Advil three times per day: Morning, Noon,

& Night, she does not know the exact dose other than stating “they are not extra strength. She

also reports taking Tylenol for occasional headaches. Denies taking any vitamins or

supplements.

Allergies

Ms. Jones is allergic to cats and penicillin. Cats trigger her asthma and causes wheezing,

sneezing, and itching. Her Penicillin allergy causes rash and hives.

Medical History

Ms. Jones has uncontrolled and unmonitored type II diabetes. She has a open right foot

wound that she sustained one week ago will stepping on a stool barefoot. She has asthma and

was last hospitalized for asthma when she was in high school. She has experienced an

unexpected weight loss of ten pounds. She states that she has been excessively thirsty. She is

experiencing nocturia. Her menstrual periods are irregular and heavy, with her last menstrual

period being three weeks ago.

Health Maintenance

Ms. Jones’ last Pap smear was more than four years ago. Her last eye exam was during her

childhood. Her last dental exam was a few years ago. Her last PPD was negative approximately

years ago. She does not exercise. Her typical diet consists of breakfast: a muffin or pumpkin

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TINA JONES HEALTH HISTORY NARRATIVE

bread; lunch: a sub sandwich; dinner: meatloaf or chicken with soup; snacks: pretzels or when

she wants to treat herself French fries.

Immunizations

She reports a tetanus booster a couple of years ago. She did not receive an influenza vaccine this

year and it has been several years since her last influenza vaccine.. She is up to date with

childhood vaccines.

Family History

Ms. Jones’ mom is fifty years old. She has a medical problems both hyperlipidemia and

high blood pressure. Her dad is deceased at fifty-eight years in age from a motor vehicle

accident that occurred last year. Her father also had a history of high blood pressure,

hyperlipidemia, and type II diabetes. Her paternal grandmother has high blood pressure. Her

paternal grandfather (Grandpa Jones) died in his early sixties from colon cancer. He had a

history of type II diabetes. Ms. Jones’ maternal grandmother (Nana) died at age seventy-three

from a stroke. Her Nana also had a history of high blood pressure and hyperlipidemia. Her

maternal grandfather (Poppa) died at age seventy-eight from a heart attack. He also had a history

of high blood pressure and hyperlipidemia. Ms. Jones has a younger sister and also has asthma.

Her brother has no known medical problems, but Ms. Jones reports that he is overweight as well

as most of her family. Her paternal uncle is an alcoholic.

Social History

Ms. Jones is very active in church and with family. She goes out occasionally with friends

dancing. She also enjoys bible study and volunteering with her church. She previously lived

alone, but moved back in with her mom and younger sister to help with finances and to help care

for her sister after the death of her father. She is working on her bachelor’s degree in accounting.

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TINA JONES HEALTH HISTORY NARRATIVE

She does not use tobacco products and is exposed to secondhand cigarette smoke when she is out

with friends. She does not use drugs, but tried pot when younger. Ms. Jones drinks diet coke

soda. She drinks socially only two to three times per month when out with friends. She is

currently single. She is currently not on contraceptives, but used birth control while sexually

active with previous partner. She is not currently sexually active. She has never been married

and has never been pregnant. She has had a total of three (guy) partners, and has never been

diagnosed with any STI ‘s.

Subjective Data

HEENT

Ms. Jones states that she gets headaches when reading or studying. These headaches feel tight

and throbbing behind her eyes. The headaches last for a couple of hours. She takes Tylenol to

help with the headaches. There is no family history of headaches. She denies any head trauma.

Patient states that her vision gets blurry when reading or studying. She states that her eyes do not

hurt when her vision gets blurry. Her eyes get red and itchy when she is around cats. She also

sneezes and experiences rhinitis and congestion around cats. She has not had an eye exam since

childhood. She does not wear glasses or contacts. She states that she has no problems with her

mouth. She states that her nose is fine, denies nasal discharge. She states that her hearing is fine.

There is no family history of hearing problems. She denies head and neck trauma, ringing in the

ears, ear pain, discharge, and loss of balance. She does not have a history of sinus problems,

frequent colds or infections. She denies difficulty swallowing and changes to her voice. She

denies any dental issues and has not gone to the dentist since she was a kid. She has not had any

changes in her taste.

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TINA JONES HEALTH HISTORY NARRATIVE

Cardiovascular

Ms. Jones denies cough, chest pain, palpations, dyspnea on exertion, dyspnea, peripheral

edema, varicosities, she states other than her right foot she does not have pain in lower

extremities. She denies a history of cardiac problems, stroke, and heart attack.

Respiratory

Patient states that she has not had a full-blown asthma attack in years, but had to use her

inhaler a few days ago when she was visiting her cousin. Cats are what usually triggers

problems with her asthma. She states that she is allergic to cats. She was able to breathe

normally after a few puffs of her inhaler. She uses a regular Proventil inhaler since she was a

kid. Her younger sister also has asthma. She denies: cough, shortness of breath, chest pain, and

congestion. She admits that she gets congested around cats. Her sister rarely has issues with her

asthmas. She denies smoking, drug use, and she denies the use of tobacco. She is only around

second hand smoke when she goes out with friends. She has been hospitalized as a child and in

high school for problems with her asthma. She denies a history of TB, chest pain, difficulty

breathing, and cough.

Abdominal

Ms. Jones denies digestive problems. She states that she has recently lost ten pounds

without trying over the past month. She denies flank pain, dysuria, and urgency. She denies

UTI’s. She also states that she is really thirsty and has been drinking a lot of water. She denies,

reflux,