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 pe
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
C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m
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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.”
Document: Provider Notes – NURS 6512
C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m
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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.
Document: Provider Notes – NURS 6512
C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m
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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
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
2
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 hospital
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