ADVANCING
YOUR PRACTICE
Documenting
a patient’s initial assessment
Depending on where you work, you may hear initial
assessment information referred to by different names, including
“nursing admission assessment” and “nursing
database.” Some facilities have adopted initial assessment
forms that include information gathered from different members
of the healthcare team, such as physicians, nurses, advanced practitioners,
social workers, physical or occupational therapists, nutritionists,
and pastoral care workers. These forms may be called “integrated,”
“interdisciplinary,” or “multidisciplinary”
care team assessment forms.
Documentation styles and formats vary, depending
on the facility's policy and the patient population. Furthermore,
healthcare facilities have different policies for documenting
learning needs, discharge planning, and incomplete initial assessment
data. You must be familiar with your facility's standards to document
your initial assessment findings appropriately.
Documentation styles
Initial assessment findings are documented in one of three basic
styles: narrative notes, standardized open-ended style, and standardized
closed-ended style. Many assessment forms use a combination of
all three styles.
Narrative notes consist of handwritten accounts
in paragraph form, summarizing information obtained by general
observation, interview, and physical exam.
Although narrative notes allow you to list your
findings in order of importance, they also pose problems. In many
cases, the notes mimic the medical model by focusing on a review
of body systems. They're also time-consuming—both to write
and to read. In addition, narrative notes require you to remember
and record all significant information in a detailed, logical
sequence—often an unrealistic goal in today's hectic world
of healthcare. Finally, difficulty in interpreting handwriting
can easily lead to misinterpretation of findings.
Narrative notes are most practical for independent
practitioners. Within healthcare institutions, however, exclusive
use of narrative notes wastes time and may jeopardize quality
monitoring.
The standardized open-ended assessment form is
a typical “fill-in-the-blanks” form that comes with
preprinted headings and questions. This form saves you time in
a couple of ways. Information is categorized under specific headings,
so you can easily record and retrieve it. And the form can be
completed using partial phrases and approved abbreviations.
Unfortunately, however, open-ended forms don't
always provide enough space or instructions to encourage thorough
descriptions. Thus, under the heading type of dwelling, one nurse
may write “apartment,” whereas another may write “apartment
in four-flight walk-up, without heat or hot water.”
Nonspecific responses can lead to misinterpretation.
For instance, a nurse may write that a patient performs a task
“within normal limits.” But unless normal limits have
been defined, this notation is neither clear nor legally sound.
The standardized closed-ended assessment form
provides preprinted headings, checklists, and questions with specific
responses. You simply check off the appropriate response.
In addition to saving time, the closed-ended form
eliminates the problem of illegible handwriting and makes checking
documented information easy. The form can also be easily incorporated
into most computerized systems.
This kind of form also clearly establishes the
type and amount of information required by the healthcare facility.
And even though the closed-ended forms usually use nonspecific
terminology, such as “within normal limits” or “no
alteration,” guidelines clearly define these responses.
The closed-ended form also has some disadvantages.
For instance, many of them don't provide a place to record relevant
information that doesn't fit the preprinted choices. In addition,
the form tends to be lengthy, especially when a facility's policy
calls for recording in-depth physical assessment data.
Documentation formats
Historically, nursing assessment has followed a medical format,
emphasizing the patient's initial symptoms and a comprehensive
review of body systems. Although many healthcare facilities still
use a medical format to organize their nursing assessment forms,
some facilities have adopted formats that more readily reflect
the nursing process.
Most facilities that use a nursing format for
assessment base it on either human response patterns or functional
healthcare patterns. Other documentation formats are modeled on
specific conceptual frameworks based on published nursing theories.
Integrated admission database
form
Most healthcare facilities use a multidisciplinary admission form,
with spaces that can be filled in by the nurse, physician, and
other healthcare providers.
The North American Nursing Diagnosis Association-International
(NANDA-I) has developed a classification system for nursing diagnoses
based on human response patterns. These patterns relate directly
to actual or potential health problems, as indicated by assessment
data.
Thus, when you use an assessment form organized
by these patterns, you can easily establish appropriate diagnoses
while you record assessment data—especially if a listing
of diagnoses is included with the form. The main drawback is that
these forms tend to be lengthy.
Some healthcare facilities organize their assessment
data according to functional healthcare patterns. Developed by
Marjory Gordon, this system classifies nursing data according
to the patient's ability to function independently. Many nurses
consider functional healthcare patterns easier to understand and
remember than human response patterns.
Documenting learning needs
Most initial assessment forms have a separate section for documenting
a patient's learning needs. When you reassess your patient's learning
needs, you can document your findings in the progress notes, on
an open-ended patient education flow sheet, or on a structured
patient education flow sheet designed for a specific problem such
as diabetes mellitus.
Documenting discharge planning
needs
Effective discharge planning begins when you identify and document
the patient's needs during the initial assessment. Depending on
the policy at your healthcare facility, you'll record the patient's
discharge needs on the initial assessment form (in a designated
section), on a specially designed discharge planning form, in
a separate section on the patient-care card file, in the progress
notes, or on a discharge planning flow sheet.
Documenting incomplete initial
data
No matter what assessment tool you use, you may not always be
able to obtain a complete health history during the initial assessment
(the patient may be too ill to participate, and secondary sources
may be unavailable). When this occurs, base your initial assessment
on your observations and physical exam of the patient. When documenting
your findings, be sure to write a comment such as “Unable
to obtain complete data at this time.” Otherwise, it might
appear that you failed to perform a complete assessment.
Try to obtain missing information as soon as possible,
either when the patient is able to provide the information or
when family members or other secondary sources are available.
Be sure to record how and when you obtained the missing data.
Depending on your facility's policy, you may record the information
on the progress notes, or you may return to the initial assessment
form and add the new information along with the date and your
signature. Both methods have advantages and disadvantages.
Adding to the initial assessment form makes it
easy to retrieve the data when it's needed—either during
the patient's hospitalization or after discharge for quality assurance.
Putting the information into the nursing progress notes aids in
the day-to-day communication with others who read the notes, but
also makes it difficult to retrieve the data later.
When you add information to complete an initial
assessment, be sure to revise your nursing-care plan accordingly.
Selected reference
Complete Guide to Documentation. 2nd ed. Philadelphia,
PA: Lippincott Williams and Wilkins; 2008:103–111.
Source: LPN2009. May/June
2009.
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