Which source of information does the nurse refer when performing a patient history?
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Sarah Rhynas Teaching fellow in nursing studies, University of Edinburgh History taking is a key component of patient assessment, enabling the delivery of high-quality care. Understanding the complexity and processes involved in history taking allows nurses to gain a better understanding of patients’ problems. Care priorities can be identified and the most appropriate interventions commenced to optimise patient outcomes. Nursing Standard. 26, 24, 41-46. doi: 10.7748/ns2012.02.26.24.41.c8946 Correspondence
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Subscribe RCN student member? Try Nursing Standard StudentAlternatively, you can purchase access to this article for the next seven days. Buy now Or Open Resources for Nursing (Open RN) Using Technology to Access InformationMost patient information in acute care, long-term care, and other clinical settings is now electronic and uses intranet technology for secure access by providers, nurses, and other health care team members to maintain patient confidentiality. Intranet refers to a private computer network within an institution. An is a real-time, patient-centered record that makes information available instantly and securely to authorized users.[1] Computers used to access an EHR can be found in patient rooms, on wheeled carts, in workstations, or even on handheld devices. See Figure 2.11[2] for an image of a nurse documenting in an EHR. Figure 2.11 Nurse Documenting in EHRThe EHR for each patient contains a great deal of information. The most frequent pieces of information that nurses access include the following:
View a video of how to read a patient’s chart.[3] Legal DocumentationNurses and health care team members are legally required to document care provided to patients. In a court of law, the rule of thumb used is, “If it wasn’t documented, it wasn’t done.” Documentation should be objective, factual, professional, and use proper medical terminology, grammar, and spelling. All types of documentation must include the date, time, and signature of the person documenting. Any type of documentation in the EHR is considered a legal document and must be completed in an accurate and timely manner. Abbreviations should be avoided in legal documentation. Documentation is used for many purposes. It is used to ensure continuity of care across health care team members and across shifts; monitor standards of care for quality assurance activities; and provide information for reimbursement purposes by insurance companies, Medicare, and Medicaid. Documentation may also be used for research purposes or, in some instances, for legal concerns in a court of law. Documentation by nurses includes recording patient assessments, writing progress notes, and creating or addressing information included in nursing care plans. Nursing care plans are further discussed in the “Planning” section of the “Nursing Process” chapter. Common Types of DocumentationCommon formats used to document patient care include charting by exception, focused DAR notes, narrative notes, SOAPIE progress notes, patient discharge summaries, and Minimum Data Set (MDS) charting. Charting by Exceptiondocumentation was designed to decrease the amount of time required to document care. CBE contains a list of normal findings. After performing an assessment, nurses confirm normal findings on the list found on assessment and write only brief progress notes for abnormal findings or to document communication with other team members. Focused DAR NotesFocused DAR notes are a type of progress note that are commonly used in combination with charting by exception documentation. stands for Data, Action, and Response. Focused DAR notes are brief. Each note is focused on one patient problem for efficiency in documenting and reading.
View sample charting by exception paper documentation with associated DAR notes for abnormal findings. View a video explaining F-DAR charting.[4] Narrative Notesare a type of progress note that chronicles assessment findings and nursing activities for the patient that occurred throughout the entire shift or visit. View sample narrative note documentation according to body system in each assessment chapter of the Open RN Nursing Skills textbook. SOAPIE Notesis a mnemonic for a type of progress note that is organized by six categories: Subjective, Objective, Assessment, Plan, Interventions, and Evaluation. SOAPIE progress notes are written by nurses, as well as other members of the health care team.
Patient Discharge SummaryWhen a patient is discharged from an agency, a discharge summary is documented in the patient record, along with clear verbal and written patient education and instructions provided to the patient. Discharge summary information is frequently provided in a checklist format to ensure accuracy and includes the following:
See Figure 2.12[5] for an image of a nurse providing discharge instructions to a patient. Discharge teaching typically starts at admission and continues throughout the patient’s stay. Figure 2.12 Discharge TeachingMinimum Data Set (MDS) ChartingIn long-term care settings, additional documentation is used to provide information for reimbursement by private insurance, Medicare, and Medicaid. The Resident Assessment Instrument is a federally mandated assessment tool created by registered nurses in skilled nursing facilities to track a patient’s goal achievement, as well as to coordinate the efforts of the health care team to optimize the resident’s quality of care and quality of life.[6] This tool also guides nursing care plan development. Read more details about MDS charting in the Long-Term Care Facility Resident Assessment User Manual established by the Centers for Medicare and Medicaid Services (CMS). What type of information does the nurse gather from the patient during the nursing history?Nursing staff should discuss the history of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status, implants and family and social history.
Who is the primary source of data in collecting the patient history?During a health history, the nurse collects subjective data from the patient, their caregivers, and/or family members using focused and open-ended questions.
What are the 2 kinds of data obtained during history taking?Data gathered may be subjective or objective in nature.
What are the sources of data in nursing?The client is the primary source of data. Family members or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literature are called secondary sources. The primary methods used to collect data are observing, interviewing, and examining.
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