LPN2009
May/June 2009
Volume 5 Number 3
Pages 4 - 7
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. (For an example of the first page of a typical integrated admission database form, see Integrated admission database form.)
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.
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.
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.
Most healthcare facilities use a multidisciplinary admission form. The sample form below has 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.
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.
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.
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.
Complete Guide to Documentation. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008:103–111.
No comments:
Post a Comment