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Clinical Nursing Skills

4.2 Data Collection and Documentation

Clinical Nursing Skills4.2 Data Collection and Documentation

Learning Objectives

By the end of this section, you will be able to:

  • Identify the major components of a complete health history
  • Explain the difference between subjective and objective data
  • Describe effective verbal and nonverbal communication techniques to collect patient data

Before meeting the patient and beginning the health assessment, the nurse should review the patient’s health record, if it is available (Figure 4.4). Knowing the patient’s demographic data is useful in deciding how to proceed with the assessment process. Information pertaining to past medical history, medications, and chronic diseases can be used to guide clinical decisions regarding current health status. Nurses should educate themselves regarding the patient’s current medications or previous test performed to determine interview questions and apply critical reasoning. The nurse should validate all data with the patient and add to the information if needed.

A color photograph of a nurse reviewing a patient's medical record on a portable computer stand in a hospital hallway.
Figure 4.4 Reviewing the patient’s medical record is an important part of preparing for the assessment. (credit: modification of “Portable Information station, nurse, computer, hand wipes, 9th floor, Virginia Mason Hospital, Seattle, Washington, USA” by Wonderlane/Flickr, CC BY 2.0)

Once you have reviewed the patient’s basic health data, it is time to take a moment and reflect on your own personal feelings. Sometimes patient situations can illicit personal feelings for the nurse. Examples of situations that may require the nurse to reflect on personal biases include:

  • drug addiction
  • mental illness
  • teenage pregnancy
  • active sexually transmitted disease(s)
  • special needs or cognitive challenges
  • obesity or lack of health consciousness

It is imperative that the nurse remove all personal biases before interacting with the patient. According to the American Nurses Association’s Nursing Code of Ethics, personal biases can cause judgment, and the potential to project those judgments on the patient, and need to be avoided (ANA, 2022). Nurses should be as objective and open as possible when interacting with patients. Patients need to feel safe and free from negativity while receiving care.

Components of the Health History

During the assessment phase of the nursing process (see Table 4.1), the nurse completes four steps. The four steps include collecting subjective data, collecting objective data, validating the data, and documenting the data. Although there are four separate steps, they are fluid in nature and often overlap, and you may find yourself performing multiple steps concurrently. For example, you may ask your patient about skin concerns while you are inspecting their skin. If they answer that they do not have any concerns but you notice that the skin on the lower extremities is weeping (leaking fluid) and red, validation is initiated.

Documentation of data in the health record is broken down into different components.

The structure of health records can vary between practice settings, but they are all composed of these common components: demographic data, chief complaint or history of present illness, past medical history, past family and/or social history, and review of systems (ROS). Health records also contain areas to document current findings such as assessment data, diagnosis, treatment plans, and a follow-up plan for evaluation (Figure 4.5 and Figure 4.6).

The first page of a blank patient health history form. It includes spaces for the patient's name, address, date of birth, age, gender, phone number, email address, reason for visit, allergies, medications, hospitalizations, surgeries, tobacco use, illegal drug use, alcohol use, past medical issues, current symptoms, and substance abuse.
Figure 4.5 The nurse goes through all components when conducting a comprehensive health history. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
The second page of a blank patient health history form. It includes spaces for sexual history, gynecologic history, gynecologic symptoms, and family medical history.
Figure 4.6 The health history is comprehensive. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Subjective Data

The information a patient provides the nurse with can indicate diseases or conditions in the body. The subjective data is information obtained from the patient and/or family members and can provide important cues about functioning and unmet needs requiring assistance. Subjective data is considered a symptom because it is something the patient reports. Examples include pain, dizziness, sadness, hunger, or restlessness. The major areas of subjective data include demographic data, chief complaint, ROS, and the patient’s past personal, family, and social history. Subjective data can be collected from a primary source, the patient, or from a secondary source. Examples of a secondary source include information obtained from the history section of the health record, or the patient’s family. If data are gathered from someone other than the patient, the nurse should document where the information is obtained.

Demographic Data

The demographic data consist of identifying basic patient information. Data such as name, date of birth, contact information, race, gender, preferred pronouns, marital status, occupation, religion, allergies, and resuscitation status are included in this component. Other data in this section may include consent forms and the patient’s health insurance or entity responsible for payment of services rendered.

Demographic data are used for both administrative and clinical purposes. Administrative examples include payment collection and confirming upcoming appointments. Clinical examples include health promotion, like cancer screening for certain populations. Demographic data should be reviewed with each patient encounter to ensure changes to the information are documented.

Patient’s Chief Complaint

After recording the patient’s basic information and reviewing it for accuracy, it is time to find out why the patient is seeking medical care. The chief complaint is a statement of the signs and symptoms that have caused the patient to seek medical attention. The chief complaint can be revealed through open-ended questioning. The interview technique of open-ended questioning involves more than a yes or no answer; it requires the patient to provide details in their response. Sample questions the nurse can ask are outlined in Table 4.2. Examples of a patient’s response to an open-ended question about onset may include, “I have been unable to sleep for the last five nights,” “I was planting rose bushes and a thorn stabbed my finger, and it has been throbbing for three days,” or “Yesterday, I slipped coming down my stairs and hurt my back.” Once the nurse has determined the patient’s chief complaint, it is important to continue to probe for more detailed information surrounding the event. Avoid using questions that suggest a response from the patient, such as “Your pain is sharp, right?”; instead, the nurse should ask the patient to describe the pain in their own words.

Information Domain Examples of Open-Ended Questions
Onset “How long ago did this first begin”
Severity “Please describe the pain”
Location “Please explain exactly where the pain is located”
Self-care “What medications have you taken for this” or “Please describe anything that has helped in the past”
Quality “Please describe anything you do that makes it feel better or worse”
Duration “When was the last time you experienced pain like this?”
Table 4.2 Examples of Open-Ended Questioning

The nurse should ask if the patient is taking an over-the-counter medication, or a medication that does not require a prescription, as well as an alternative substance such as a nonregulated herbal substance or homeopathic medication. It is valuable for the nurse to recognize that what Western medicinal practice considers “alternative” may be the mainstay of home remedies used for specific cultures and not alternative at all. A good question for the nurse to ask would be, “What nonprescription medications, herbal supplements, or vitamins do you currently take?” It is also important to remember that not all patients visit the physician’s office because of an illness or acute event. Some patients are seeking health promotion such as routine examinations or yearly bloodwork. These patients would have a chief complaint documented as annual examination or routine physical appointment.

Cultural Context

Cultural Considerations When Collecting a Comprehensive Health History

Culture is complex and changes with external and internal influences. Meeting patients’ cultural needs is just as important as meeting their physical needs. Mastering cultural competency is essential in providing high-quality care and improving patient outcomes. Nurses should ask questions related to the patient’s cultural preference and traditions to improve patient care outcomes. Examples might include dietary preferences, or end-of-life issues. Nurses should attempt to extract information the patient might not be so forthcoming to share. Examples include how modesty or gender roles are practiced in a specific culture. Using therapeutic communication techniques, the nurse can build a trusting relationship that will enhance the patient’s willingness to share information. Promoting cultural communication contributes to reducing racial and ethnic disparities (Weatherspoon et al., 2016).

Past Health

The past health component of a medical record addresses all of a patient’s previous medical history including personal, family, and social history. The personal history component includes any diagnosis or previously experienced condition, treatment, or surgery. Some examples include diagnoses of diabetes, hypertension, myocardial infarction, pregnancy, or birth. The nurse should ask questions pertaining to childhood illnesses and immunizations to date, and any food, medication, or environmental allergies. Other examples of information include past surgeries or hospitalizations. Information regarding past health status allows the healthcare team to plan appropriate care for any present illness.

Family Health

The family history component contains information related to familial diseases or hereditary conditions. A familial disease tends to occur more often in a particular family. Familial diseases often have a genetic component affecting more members of the family than perhaps they would be affected by chance alone, for instance, high blood pressure or cholesterol. Consider the scenario that follows:

  • A 42-year-old male patient presents to your clinic for treatment of consistently high blood pressure readings at home. The patient describes an active lifestyle and dietary choices that are nutritious in nature. He goes on to explain his father had high blood pressure and died of heart disease at age seventy-four years, and his mother, while still living, has had two strokes related to high blood pressure. Based on the patient’s family health history and no other risk factors, it is considered his high blood pressure is familial in nature.

Hereditary Diseases

A hereditary disease is passed down from generation to generation. Some examples of hereditary diseases include Down syndrome, cystic fibrosis, Tay-Sachs disease, Marfan syndrome, and sickle cell anemia. It is important to ask the patient to recall any information regarding the health status of maternal and paternal grandparents, parents, and siblings. Often genograms are used to help visualize a patient’s family history. Figure 4.7 shows a sample genogram.

A color genogram with symbols for the following issues: asthma, cancer, depression, diabetes, heart disease, deceased, pregnancy.
Figure 4.7 A genogram can help track a family history of diseases. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Social Health

The social history component includes the patient’s lifestyle choices and daily behaviors. Questions related to diet, hobbies, alcohol and tobacco use, sexual history, or other behaviors that place a patient at risk can also be found in this component. Health promotion education provided to a patient can often be derived from information discovered in the social history section of a health record. For example, if a nurse discovered a patient uses tobacco products, then they could provide smoking cessation education.

Review of Systems

A comprehensive review of each body system (ROS), such as cardiovascular, musculoskeletal, or urinary, can reveal information the patient may have forgotten to mention previously. Sometimes patients think information may be irrelevant and do not want to take up valuable time discussing what they think is not pertinent information. For example, brittle, peeling, or indented nails can seem like a harmless condition for most people, but it can also be a symptom of cardiac issues. Symptoms or questions related to certain diseases are included in this component. Asking the patient questions in terminology they understand will allow them to describe the status of each body system. A sample review of systems is shown in Figure 4.8 and Figure 4.9.

The first page of a blank review of systems assessment guide. It includes requests for the following information. Name, date of birth, height and weight, allergies, skin/hair/nails, eyes, ears, nose/sinuses/mouth/throat, neck, breasts, respiratory, heart, peripheral vascular, gastrointestinal, urinary, and malegenitalia/reproductive.
Figure 4.8 The ROS helps ensure that a patient has not forgotten an important component of their health history. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
The second page of a blank review of systems assessment guide. It includes requests for the following information. Female genitalia/reproductive, hematolymphatic, endocrine, musculoskeletal, neurological, and mental status.
Figure 4.9 The ROS is lengthy but important. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Life-Stage Context

Nutritional Status in Older Adults

The ability to smell and taste decreases with age. Medications and some degenerative conditions can also decrease sense of smell and taste in older people. Nurses should ask questions regarding current nutritional status and analyze correlation to age-related decreased sense of smell and taste (National Institute on Aging, 2020).

Suggested questions:

  • How has your appetite been lately?
  • Do you eat alone or with others?
  • How many times a day do you eat?
  • Do you use a lot of salt or sugar on your food?
  • Can you taste sour or bitter things like you used to?
  • Have you noticed a change in the way food smells?

Objective Data

Information observed through your senses of hearing, sight, smell, and touch while assessing the patient is objective data, also called signs. Examples include vital signs, laboratory results, and physical examination findings. Subjective and objective data are often collected and documented together. For example, if a patient says “I am feeling dizzy” and has a recorded blood pressure of 88/52, the feeling of dizziness is a subjective symptom, and the recorded blood pressure is an objective sign. It is important for the nurse to recognize the difference between subjective versus objective information. Table 4.3 provides a comparison.

Subjective Data (Symptoms) Conceptual Problem Objective Data (Signs)
Patient states,
“I am worried about my breast cancer diagnosis. How do I tell my children and husband?”
Anxiety and coping Patient presents with:
  • increased heart rate at 126
  • increased respirations at 26
  • clenched hands
  • poor eye contact and tear-filled eyes
Patient states,
“I think may be sick. My skin feels warm, but I am so cold my body is shivering. My head and chest hurt.”
Thermoregulation, oxygenation, and immunity Patient presents with:
  • temperature of 101.8°F
  • pain rating of 8/10 for headache
  • productive cough with thick yellowish-green sputum
  • diminished bilateral breath sounds and rhonchi noted
Patient states,
“I have been nauseous and had diarrhea for two weeks. The smell of food makes me want to vomit.”
Fluid volume deficient, nutrition, elimination, and immunity Patient presents with:
  • approximately 400 mL liquid brown stool with strong odor
  • stool sample positive for gram-positive bacterium: Clostridium difficile
  • recent laboratory work includes:
    • BUN 50 mg/dL
    • creatinine 1.3 mg/dL
    • urine positive for ketones
Table 4.3 Comparison of Subjective versus Objective Data Related to Coping

Vital Signs and Anthropometric Measurements

The first set of objective data collected is called vital signs, also known as cardinal signs, which are measurements of the body functions that are essential to maintain life. Vital signs frequently assessed and recorded by the nurse include temperature, heart rate, respiration rate, blood pressure, and pain level. Also recorded in this component of the health record are anthropometric measurements, a patient’s height and weight. Each specific vital sign is discussed in detail in Chapter 15 General Survey, Anthropometric Measurement, and Vital Signs. Vital signs are the most important objective data to be collected (Sapra et al., 2022). Vital signs give the healthcare team an overall glimpse of what is going on inside the body at any given moment.

Patient Conversations

What If Your Patient Appears Anxious about Routine Procedures?

Scenario: Nurse walks into the patient’s room to complete an assessment and the patient starts exhibiting signs of fear and anxiety. The patient pulls the covers up to their chest and is clenching them tightly. The patient will not take their eyes off the portable vital sign machine.

Nurse: Hi, my name is Sara, and I am going to be your nurse today. Do you mind verifying your name and date of birth for me?

Patient: uhm . . ., sure its Jon Blankenship and 01/12/1952. What are you going to do to me?

Nurse: Hi, Mr. Blankenship, I would like to assess your vital signs, if that is okay?

Patient: What does that mean? Does it hurt? Just a minute ago, they brought a machine in here and took blood from my finger and it still hurts. They said they were assessing my blood sugar levels, but I don’t have blood sugar problems or diabetes. I am afraid you all do not know what you are doing, and I want to go home.

Nurse: Mr. Blankenship, I can understand your fear. Let me try and explain; we recognize you do not have a diagnosis of diabetes. Your physician wants us to monitor your blood sugar levels because the new medication he started you on for your chronic obstructive pulmonary disease (COPD) can cause blood sugar levels to get extremely high in some patients, and we just want to keep an eye on things for your safety.

Patient: Oh, well that makes sense. Then what is that machine for again?

Nurse: This is a portable vital sign machine that lets me check your heart rate, blood pressure, and temperature. If all is well, we only need to check your vital signs every six hours while you are here. If any of your vital signs changes drastically, then we may have to monitor more frequently. While obtaining vital signs does not hurt, the pressure on the blood pressure cuff can feel like a tight squeeze but won’t last long. May I go ahead and complete them now?

Patient: It is okay. You can go ahead but go slow.

Scenario follow-up: The nurse collects the patient’s pain level, heart rate, respiration rate, blood pressure, and temperature. She uses the bed scale to collect his current weight.

Nurse: Okay, I am done; your vital signs are good and are within the range of what we like to see. I know you said you want to go home. I understand being in the hospital is scary and not what you are accustomed to, but it truly is the best place for us to monitor your health right now. Do you think you would be willing to stay a bit longer with us?

Patient: Yes, I will stay for a little longer. It really is not bad here. I think, maybe, I just really miss my wife. We have been married 53 years and have never stayed a day apart.

Nurse: Would you like me to call her so you can talk to her on the phone? She is also allowed to come sit with you. We always encourage a loved one to visit. It helps with your healing process.

Patient: Oh, that would be wonderful! Yes, please call her, here is my phone number.

Physical Findings, Laboratory and Radiology Reports

A physical finding refers to the assessment of each body system. The nurse completes a head-to-toe organized approach to discover physical findings within each body system. Unit 4: Health Assessment and Promotion discusses each body system and accompanying assessment in detail. Other diagnostic information found in this component of the health record includes laboratory and radiology reports. Laboratory reports include data related to the body’s blood and chemistry. Radiology reports consist of information related to x-rays, MRI, computed tomography, or any other form of imaging. Physical findings and laboratory and radiology reports can assist the nurse in determining correct interventions for the care plan as well as evaluating effectiveness of the selected intervention.


The diagnosis component of the chart is where the provider will document the identification of any diseases or conditions. The physician will use information from all the components of the health record to determine a plan of action and diagnosis for the patient. It is important to remember the professional nurse does not provide the patient with a medical diagnosis. Only the physician and other advance practice certified providers, such as a nurse practitioner or physician’s assistant, can provide a medical diagnosis. The medical diagnosis directs medical treatment and guides the whole healthcare team on how to treat the patient.

The professional nurse develops nursing diagnoses as part of the patient’s plan of care. A nursing diagnosis describes a problem that a nurse can treat within their scope of knowledge, skills, and license. It provides guidance for the nurse on which interventions should be utilized to alleviate signs and symptoms associated with the medical diagnosis.

A collaborative problem is a certain physiological response the nurse monitors that can be addressed through nursing intervention and physician-prescribed treatments. This type of problem can be described as a potential risk for status, such as increased respirations or increased heart rate. Collaborative problems involve all healthcare team members to achieve the goal. Table 4.4 shows examples of all three types of diagnoses. This component of the health record is reserved for the medical diagnosis.

Patient has come into the emergency room and is experiencing a heart attack
Medical Diagnosis Nursing Diagnosis Collaborative Problem
  • Myocardial infarction without ST elevation
  • Altered tissue perfusion
  • Fear
  • Pain
  • Deficit knowledge
  • Dizziness
  • Dysrhythmias
  • Decreased urinary output
  • Fluid retention
What treatment is needed for each type of diagnosis, and who will complete the task
  • Laboratory and diagnostic testing is to be completed by the phlebotomy and radiology departments.
  • Medication is to be filled by the pharmacy and then administered by nursing. Oxygen therapy and management are to be delivered by the respiratory department.
  • Nurse initiates continuous cardiac monitoring and anticipates the need for insertion of an arterial catheter, pulmonary artery catheter, or both to evaluate hemodynamic status.
  • Nurse provides emotional support and assists the patient in using positive coping strategies to reduce fear and anxiety.
  • Nurse informs the patient and family about the condition, treatment.
  • Nurse answers any questions they have clearly and in terms that they can understand.
  • All healthcare team members will monitor the patient for safety risks and assist as needed.
  • Cardiac technicians will monitor the continuous telemetry and notify the nurse of any changes to rhythm.
  • Laboratory will complete the orders for bloodwork, and nursing will analyze the results and notify the physician of any critical values.
  • Nursing monitors urinary output for potential risks of kidney failure.
Table 4.4 Medical Diagnosis, Nurse’s Diagnosis, and Collaborative Problems Medical diagnosis guides the overall treatment plan of the patient. Nursing diagnosis describes common patient problems associated with the medical diagnosis. Collaborative problems identify risk factors associated with a change in the patient’s condition (Source: Amsterdam et al., 2014).

Treatment Prescribed, Progress Notes, and Patient Education

The next component of the health record includes treatment prescribed by the provider. A treatment plan is used to increase patient outcomes related to specific diseases or conditions. As these prescribed treatments are completed, it is recorded in the progress notes. The EHR can separate each progress note into a specific disciplinary team, such as provider, nurses, respiratory, and other ancillary departments. All interdisciplinary team members document treatments and interventions being done for the patient, as well as the patient’s response to the treatment. This component of the health record is also used for any provided patient education. It is important to remember that the nurse should document exactly what the patient was educated on, how the education was provided, and how the evaluation of knowledge received was determined.

Patient Conversations

Patient Education

Scenario: Nurse walks into patient room to provide education on their newly prescribed diabetic diet.

Nurse: Hi, my name is Gwen, and I am going to be your nurse today. Do you mind verifying your name and date of birth for me?

Patient: uhm . . . , sure, its Mary Goodwright and 03/17/1972.

Nurse: Hi Ms. Goodwright, I would like to take some time and discuss your new diabetic diet. Is this a good time for you?

Patient: Sure, I am confused about what I can eat now. I think I may need to donate all the food in my house.

Nurse: I understand your concerns, and I am happy to explain your new recommended diet. Let me start by saying that you do not have to donate all the food in your home. I am sure we can come up with a plan.

Patient: Oh, thank you! I also love to bake with my grandchildren, will I still be able to do that?

Nurse: Of course, you can. I have a little video that we show all patients newly diagnosed with diabetes. I also have a brochure I want to go over with you. Would you like to watch the video now and write down any questions you have? I can come back in thirty minutes, and we can discuss it.

Patient: Yes, that sounds like a plan.

Scenario update: Nurse sets video to play on a handheld device and hands the patient paper to write on and a pen. Nurse leaves the room and returns in thirty minutes.

Nurse: Hi, so what did you think of the video?

Patient: I really enjoyed it; I learned a lot of new information, and I do not feel as scared about my diet change now. I think I can do this.

Nurse: That is wonderful! Here is some written information to follow up on the video just in case you get home and cannot remember what was discussed.

Patient: This is very helpful. Thank you.

Scenario update: Gwen answers all the patient’s questions about the video instruction clearly and in terminology she can understand. Gwen goes over written material with the patient.

Nurse: Okay, Ms. Goodwright, I think you have a good understanding of your new diet. If you continue these changes in your diet and eating habits, it will have a positive effect on your health. Do you think you can name a few items from the store that you used to purchase and substitute in a more diabetic-friendly option based on your new knowledge?

Patient: Well, I previously would buy white rice and sweet cereal for breakfast. I have always eaten my white rice with butter and sugar for breakfast. Now, I will buy whole grain rice, and oatmeal for breakfast. Instead of the butter and sugar, I am going to add a few berries or yogurt. I have always loved fried chicken and a baked potato for lunch, but now I am going to switch to sweet potatoes and baked chicken breast. I have always been a big snacker, too. I love chips and cookies, but now I will snack on things like salty nuts or hard-boiled eggs.

Nurse: I am so proud of you! I see positive outcomes in your future.

Sample documentation: “Patient was educated on newly prescribed diabetic diet. Written material and visual instruction were used to educate the patient. Patient returned demonstration by correctly verbalizing several diabetic-friendly meal choices and repeated back information learned from the video presentation.”

Documentation of the Patient Assessment

Documentation of information obtained in the patient assessment is a crucial step in the nursing process. The primary rationale for documentation is to facilitate effective communication between the interdisciplinary health-care team members and guide quality patient care. Documented data are the foundation for formulating clinical reasoning regarding patient concerns, medical diagnosis, nursing diagnosis, and collaborative problems. Making decisions about patient care without the needed supporting documentation can result in poor patient outcomes.

The importance of documentation is addressed by each U.S. state’s Nurse Practice Act, accreditation, and reimbursement agencies, such as The Joint Commission, and the Centers for Medicare and Medicaid Services (CMS). Healthcare facilities have developed policies and procedures that provide the nurse with not only the standards for what should be documented but also assistance in accomplishing the task. The components within the EHR are designed to ensure the nurse gathers all relevant data needed to meet the standards and guidelines for each individual facility.

Real RN Stories

Listening and Assessing a Patient

Nurse: Enoc, MSN, RN, Chief Nursing Officer
Clinical setting: Acute care hospital
Years in practice: 23
Facility location: Rural central Texas

Listening to your patient’s concerns and assessing your patient are important for the overall care in a clinical setting. One time, I had assumed care for a 77-year-old male one evening in the emergency department (ED). He was being admitted for chest pain observation. He had initial complaints of burning on the left side of his chest.

Subjectively his complaints of pain and discomfort were taken as cardiac-related symptoms due to his age and previous cardiac history. On entering the room, I noticed that the patient was fully clothed, had a peripheral IV in his hand, and had a rapid triage done. On further inspection and visiting with the patient on his level of pain and description of “burning-like pain,” I decided to place him in a gown. I did a complete assessment of his chest wall and noticed a linear rash on his left chest wall. The rash was painful to touch, and he described “burning” on the inside.

Using clinical judgment and analyzing the findings on examination, I collaborated with the ED doctor on his case. The patient was originally triaged as “chest pain” when in reality the patient was suffering from shingles. A complete cardiac workup had already been done. This lack of clinical judgment was not cost-effective, nor did it provide quality patient-centered care. As you navigate your nursing career, it is important to consider what the patient tells you (subjective data) and properly assess your patient’s (objective) data to determine appropriate outcomes. Remember, as nurses, we are patient advocates, and much of our care direction is based on our ability to perform accurate clinical assessments.

The patient was discharged home with a prescription for his symptoms of shingles, and it was a learning moment for the team. This case enacted a quality improvement policy change in our ED; from that point on, all patients were to be placed in a gown and a full skin assessment was to be completed and documented.

Corrections or Alterations to Documentation

According to research, EHRs assist in patient diagnosis, reducing errors, improving patient safety, and supporting better patient outcomes (ONC, 2019). To improve risk management and prevent liability, the documentation must be an accurate representation of what took place within a patient interaction. Keeping in mind that a health record is a legal document, if an error is noted, it needs to be corrected immediately. Each healthcare facility will have a specific policy on how to correct an error in documentation. However, most require the nurse to make an entry and note the error, and then document the correct information. Here are some examples of documentation:

  • Documentation of expected findings: Patient denies any new onset of symptoms of headaches, dizziness, visual disturbances, numbness, tingling, or weakness. Patient is alert and oriented to person, place, and time. Dress is appropriate, well-groomed, and proper hygiene. Patient is cooperative and appropriately follows instructions during the exam. Speech is clear and facial expressions are symmetrical. Glasgow Coma Scale is 15. Gait is coordinated and erect with good balance. Pupils are 4mm, equal, round and reactive to light and accommodation. Sensation intact in all extremities to light touch. Cranial nerves intact × 12. No deficits demonstrated on Mini-Mental Status Examination. Upper and lower extremity strength and hand grasps are 5/5 (equal with full resistance bilaterally). Follows commands appropriately. Cerebellar function intact as demonstrated through alternating hand movements and finger-to-nose test. Negative Romberg and Pronator drift. Balance is stable during heel-to-toe test. Tolerated exam without difficulty.
  • Documentation of unexpected findings: Patient is alert and oriented to person, place, and time. Speech is clear; affect and facial expressions are appropriate to situation. Patient cooperative with exam and exhibits pleasant and calm behavior. Dress is appropriate, well-groomed, and proper hygiene. Posture remains erect in wheelchair, with intermittent drift to left side. History of cerebrovascular accident with left-sided hemiplegia. Bilateral hearing aids in place with corrective lenses on. Pupils are 4 mm equal and round. Reaction intact right and accommodation intact right eye. Left pupil 2 mm, round nonreactive to light and accommodation. Upper extremity hand grips, nonsymmetrical due to left-sided weakness. Right hand grip and upper extremity strength strong at 4/5. Left lower extremity residual weakness, rated at 1/5, right lower extremity strength 4/5. Sensation intact to light touch bilaterally, R > L. Unable to assess Romberg and Pronator drift.

Communication with the Patient When Completing a Health Record

To be an effective healthcare member, a nurse must first learn to be an effective communicator. Good communication skills can lay the foundation for and maintain an established healthy working environment. Research proves maintaining a healthy work environment is directly linked to improved patient care outcomes and excellence in nursing practice standards (AACN, 2016). These standards include skilled communication: “Nurses must be as proficient in communication skills as they are in clinical skills” (AACN, 2016, p. 2). The same techniques used for communicating with your peers can be used to communicate with your patients.

To minimize data errors during the exchange of information, best practice techniques can be implemented when communicating. Communicate face-to-face with the patient, when possible, and maintain good eye contact (unless not culturally acceptable). After asking a question, allow the patient time to respond. Listen while the patient is talking. It is unprofessional to complete other tasks while the patient is communicating (AACN, 2016).

Verbal Communication

Verbal communication is the manner of exchanging information using oral or written words. A patient’s use of verbal communication can identify important details such as education level, developmental considerations, or geographic or cultural origins. Nurses utilize verbal communication several ways when providing patient care. Examples include interactions between patients and family, giving shift reports to the relieving nurse, communicating with physicians, and evaluating interventions.

The Joint Commission has established the Situation, Background, Assessment, Recommendation (SBAR) model of communication as the gold standard for best practice when verbally exchanging information between healthcare team members. SBAR is one of the most widely used and recognized mnemonics within the healthcare industry (Shahid & Thomas, 2018). Figure 4.10 shows a sample SBAR.

A table including details for the SBAR model. SBAR includes Situation, Background, Assessment, Recommendation. The table includes examples of questions for each component.
Figure 4.10 Following the SBAR model can improve communication among team members. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Nonverbal Communication

Information exchange without the use of words is called nonverbal communication, or body language. A patient’s body language should be observed by the nurse to reveal nonverbalized issues or problems that need to be addressed. Body language includes one’s posture, gait, level of eye contact, gestures, and facial expressions. For example, if a patient is holding on to the wall as they are walking, this could mean they feel unstable, and nursing intervention is needed. Another example might be if a patient is clenching their fist and pacing the room but states that “nothing is wrong.” The nurse should document nonverbal communication as it is observed and what action was taken to resolve the issue.

If verbal and nonverbal communication misalign, the listener can receive confusing messages. The nurse should ensure their own body language matches what they are verbalizing to the patient. For example, if a patient requests assistance to the bathroom and the nurse makes a disgusted facial expression, instantly the patient perceives unprofessional and disrespectful treatment. The patient might feel ashamed and embarrassed, neither of which is considered positive patient care outcomes. Patients need to feel safe and in a positive environment to heal; this includes positive nonverbal communication from the healthcare team.

Barriers to Communication

As the nurse begins communicating with the patient, assessment of any barriers should be conducted. Common barriers to communication include hearing or cognitive impairments, English as a secondary language, and cultural beliefs/practices. Questioning should be adjusted to adapt for any identified barriers. Using an interpreter, facing the patient when speaking, and not using medical terminology are common techniques to adjust communication for identified barriers. Social determents can also be barriers to communication and learning. Communication regarding healthcare management can be equal among patients, but that does not mean all patient outcomes are equal. The Patient Centered Assessment Method (PCAM) was designed to help identify social determinants that might affect a patient’s ability to adhere or understand the importance of adhering to a health plan (Smeets et al., 2021). The PCAM is an evidence-based tool used to assess patient complexity using the social determinants of health. The tool helps validate why some patients engage in the managing of their health care, and why other patients do not. Many organizations are available to assist with questions regarding social determinants. Examples of social determinants linked to poor health promotion include housing, finances, and employment status which may help the nurse identify other factors that are affecting a patient’s ability to manage their health. For example, if a patient is unemployed and has no transportation, this might explain the lack of seeking routine healthcare visits.


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