Trisha Economidis, MS, ARNP Lake-Sumter Community College What is a Health History? Part of a comprehensive nursing assessment Subjective data Your Patient’s Story Interviewing Techniques Maintain privacy/confidentiality Establish rapport/trusting relationship Provide a comfortable environment Communicate effectively/professionally Communication Tips Open posture at eye level with patient Limit distractions Don’t take excessive notes Beware of biased questions Conducting the Interview Directive vs. Nondirective questioning Nurse listens, clarifies, and summarizes to be sure story has been heard correctly Validate if you have questions or need more information When ending the interview: summarize, give the patient a chance to add information, leave them as comfortable as possible Interviewing Considerations Cultural Considerations Touch Eye contact Space Time Silence Interviewing Considerations Developmental/Age Considerations Infants Toddlers Preschoolers School age Adolescents Adults Older Adults Elements of the Health History Basic Patient Information Chief Complaint History of the present illness Past Health History Family History Social History Review of Body Systems Basic Patient Information Name Date of birth Age Ethnic background Marital status Address and Phone number Primary care physician Emergency contact Chief Complaint Why the patient is seeking health care Record the chief complaint in the patient’s own words in quotation marks Ex. “I’ve had chest pain since early this morning.” History of Present Illness Onset…..Duration……Location of symptoms Setting Severity Precipitating factors Alleviating factors Aggravating factors Associated symptoms Treatments Patient’s view of the cause of the symptoms Past Health History Childhood illnesses Immunizations Previous injuries Chronic medical conditions Previous hospitalizations Previous surgeries and procedures Obstetric History Past Health History, cont. Sexual History Allergies Current Medications……prescription, OTC, herbals, vitamins, home remedies Last exam date Behavioral or Mental Health issues When documenting subjective data for the cardiovascular system the nurse would include which of the following? A. Vital signs B. Peripheral pulses C. Chest pain D. Heart sounds Correct Answer: C Subjective data includes any information that the client experiences, such as perceptions of pain and other sensations within the body. Subjective data is that which can only be related to the nurse by the client. Vital signs, peripheral pulses and heart sounds are part of the objective data that the nurse identifies. A client is admitted for evaluation of upper gastrointestinal symptoms. The nurse would document which statement as objective data in the client’s medical record? A. Client states, “I have a headache.” B. Client states, “I had chicken pox as a child.” C. Client has distended abdomen and active bowel sounds. D. Client states, “I feel nauseated after eating.” Correct Answer: C Objective data is information that the nurse can directly obtain and verify. The nurse can observe distention and active bowel sounds. Family History Looking for risks for disorders with a genetic or familial tendency Parents, siblings and grandparents Genogram will give you a visual representation: Current age of each person who is alive Age at death and cause Any disorders, physical or mental, that may have genetic link Genogram Social History Educational history Occupation (think work-related health hazards) Religious, spiritual and cultural beliefs Living conditions Support systems Significant stressors Tobacco, Alcohol and Recreational drug use The nurse is gathering present health practices data while taking a health history of a client admitted for back surgery. The nurse asks the client about alcohol use. The client angrily asks, “Why do you need to know?” What is the nurse’s best response? A. “If you consume alcohol then I will need to provide alcohol counseling.” B. “I need to know because alcohol can interact with many medications.” C. “You are very defensive and this suggests you probably have an alcohol problem.” D. “I can make a referral to alcohol self-help groups for you.” Correct Answer: B Alcohol is a substance that may worsen many medical conditions and also interact with medications. Just because a client consumes alcohol does not mean that the client has an alcohol abuse problem or needs a referral for counseling or a self-help group. Review of Body Systems Subjective data obtained from the patient – NOT your physical exam Current or past problems Asking about common symptoms in a head to toe fashion A nurse is collecting data for an admission nursing history. Which question by the nurse is best to open the discussion? A. What concern has brought you to the hospital? B. Would it help to discuss your feelings? C. Do you want to talk about your concerns? D. Would you like to talk about why you are here? Correct Answer: A Rationale: This is an open-ended statement that invites the patient to communicate while centering on the reason for seeking health care What is the nurse doing when using the interviewing technique of “active listening?” A. Identifying the patient’s concerns and exploring them with “why” questions. B. Determining the content and feeling of the patient’s message C. Employing silence to encourage the patient to talk D. Using nonverbal skills to display interest Correct Answer: B Rationale: Active listening is the use of all the senses to comprehend and appreciate the patient’s verbal and nonverbal thoughts and feelings. Which are the most important nursing actions when speaking with an older adult whose hearing is impaired? Select all that apply. A. Limit background noise B. Exaggerate lip movements C. Raise the pitch of your voice D. Stand directly in front of the patient when speaking E. Raise the volume of your voice while speaking directly toward the patient’s good ear. Correct Answers: A & D Rationale: A: Limiting competing stimuli promotes reception of verbal messages D: This focuses the patient’s attention on the nurse. A hearing-impaired receiver must be aware that a message is being sent before the message can be received and decoded. When responding to questions asked during a review of systems the client reports having a sore throat, which “happens all the time.” The nurse should ask which question next? A. “When did this sore throat begin?” B. “What do you mean you have sore throats all the time?” C. “Did you also have sore throats as a child?” D. “Did you ever take antibiotics?” Correct Answer: A Knowing when the sore throat began may provide information as to whether it coincides with event, allergy, or illness. Option B sounds argumentative and is not therapeutic. Option C does not obtain useful information as children commonly have sore throats. Asking if he or she ever took antibiotics will not yield info about current medication use or info about the current sore throat. Documentation Act of recording patient status and care May be in written or electronic forms or both Record of proof Best way to prove accountability Purpose of Documentation Plan and evaluate patient care Communication between disciplines Legal documentation Quality improvement Reimbursement Education Research Principles of documentation Retrievable document Accurate, timely Effective communication Documentation Guidelines Document as soon as possible If written, legible and in black ink Only agency-approved abbreviations Use patient’s own words in “” Use concrete, specific information Record objectively – not judgments Make sure you are recording in correct client record Guidelines, cont. Date, time each entry Sign each entry with legal name, credentials Don’t leave space between entries No erasing, crossing out or correction fluid Never change another person’s charting Document all phone calls made or received related to client’s case Elements of Documentation Vocabulary – should use standardized nursing terminology Legibility Abbreviations/symbols Organization Accuracy Confidentiality Medical Record Formats How the medical record is organized Source oriented record systems Problem oriented record system Charting by exception Electronic Health Records (EHR) Source Oriented Record Systems Uses narrative charting Organized by different disciplines Drawback: Documentation for specific problem can be fragmented throughout the chart Problem oriented record system Focus is on patient’s problems or diagnoses 4 sections: Database Problem List Plan of care Progress note Charting by exception Both a format and a system of charting Nurse documents ONLY deviations from pre-established norms Uses flow sheets that have standard assessments documented and then nurse makes entry when something is outside the norm Drawback: Can lead to lazy nursing documentation Electronic Health Records Recorded via computer May be source-oriented or problem- oriented or a combination of the two See pages 296, 297 Systems of Charting Types of charting used with the medical record Charting by exception Narrative charting PIE charting SOAP/SOAPIE/SOAPIER Focus charting (DAR) Narrative Charting Story format Describes the patient’s status, interventions & treatments; and patient’s response. Very time consuming and difficult to find information May be good choice in emergency situations….simple, chronological order. Narrative charting example Smith, John Patient No. 261815 9/25/12 1800 Patient complaining of pain stating “my side is killing me.” Rates pain as a 7 on a scale of 1-10. Patient medicated with Percocet, two tabs p.o. and repositioned for comfort. P. Smith, R.N. 1850 Patient now rates pain as a 2 on a scale of 1-10. Presently ambulating in hallway. P. Smith, R.N. PIE Charting Problem Intervention Evaluation Each problem labeled and numbered Nursing notes correspond to the problem # Each to use and find info Disadvantage: Doesn’t document planning portion of nursing process PIE Charting example Smith, John 261815 9/25/12 Problem List 1. Altered comfort level 2. Altered skin integrity 9/25/12 1800 #1P: Patient states “my side is killing me.” Rates pain at RUQ incision as a 7 on a scale of 1-10. P. Smith, R.N. 1810 #1I: 1850 #1E: Patient medicated with Percocet, two tabs p.o. and repositioned for comfort. P. Smith, R.N. Patient rates pain as 2 on a scale of 1-10. Presently ambulating in hallway. P. Smith, R.N. SOAP/SOAPIE/SOAPIER S – Subjective data O – Objective data A – Assessment : Conclusion reached – Diagnoses P – Plan: Short and long-term goals/strategies for treatment I – Interventions: Actions performed to achieve outcomes E - Evaluation: Effectiveness of interventions R – Revision: Changes made to original plan SOAPIE Example John Smith 261815 9/25/12 1800 S: “My side is filling me.” O: Patient guarding RUQ incision site. Rates pain as 7 on a scale of 1-10. A: Alteration in comfort related to surgical incision. P: Medicate as needed per physicians order. Provide comfort measures. P. Smith, RN 1810 I: Patient medicated with Percocet, 2 tabs, po and repositioned for comfort.P.Smith RN 1850 E. Patient rates pain as 2 on a scale of 1-10. Presently ambulating in hallway.P Smith RN Focus Charting Not limited to problems, but also patient concerns as well. Way of organizing narrative charting DAR Format D – Data : Subjective & objective A – Action – Actions or nursing interventions R – Response – Evaluation of interventions or how the patient responded Focus Charting – DAR example John Smith 261815 9/25/12 1800 Altered comfort level related to surgical incision 1810 1850 D: Patient states “my side is killing me.” Patient observed to be guarding RUQ incision site. Rates pain as 7 on a scale of 1-10. P. Smith RN A: Patient medicated with Percocet, 2 tabs po. Patient assisted with repositioning. Dressing on RUQ incision site observed to be clean, dry and intake. P. Smith, RN R: Patient rates pain as a 2 on a scale of 1-10. Presently ambulating in hallway with family members. Observed to be standing erect and walking without the assistance of family members. The nurse documents that the client has crackles bilaterally in the lower lobes of the lungs after completing a flow sheet for other assessment data. What format of documentation is this nurse most likely using? A. Narrative notes B. SOAP notes C. Charting by exception D. PIE notes Correct Answer: C Charting by exception uses a flow sheet of established standards or normal parameters and the nurse only documents finding outside the normal parameters. Crackles in the lungs would be an abnormal finding. Other nursing documentation Nursing admission assessment Graphic flow sheets Medication administration records And others….. Also must give handoff reports SBAR – format for framing reports, conversations with other disciplines SBAR S – Situation: State your name, unit, patient’s name, room #, and the problem. B – Background – circumstances leading up to the situation, i.e. lab results, current symptoms A – Assessment – state problem or what you think is causing it (make an inference) R – Recommendation – State what you think will correct the problem or what you need from the phsician SBAR example for calling HCP S – This is Pat Smith from 3S. I’m calling about Mr. Tony Andrews in Room 321. Mr. Andrews is Very confused, crawling over the bed rails and yelling unintelligibly. B – I gave him the first dose of Demerol 50 mg iv that was ordered for pain 2 hrs ago at 2000. A – Day shift nurse reported that he was very cooperative and his conversation/behavior was appropriate. The family denies any history of “sundowning” behavior. I believe his confusion and unsafe behaviors are related to the Demerol. R – Recommendation – I would like to have an order for soft wrist restraints until he is cognizant of his behavior. Also I would like to try a different pain medication. When orienting a new nurse to a hospital unit, the nurse preceptor would reinforce which principles of appropriate documentation in the client record? Select ALL that apply. A. Accurate B. Complete C. Computerized D. Confidential E. Completed according to professional standards Correct Answers: A, B, D, E Crucial elements of documentation are accuracy, completeness, maintaining confidentiality, and completion according to standards. Whether it is computerized or not is a health systems choice rather than a principle of documentation. After the nurse gathers health assessment data on a client admitted with pneumonia, the nurse would take which action? A. Review the information gathered to analyze the data B. Report all findings to the healthcare provider C. Schedule an interdisciplinary planning meeting D. Develop appropriate client goals for identified problems. Correct Answer: A The nurse analyzes the data and then plans care for the client. Only abnormal findings are reported to hcp. Interdisciplinary care planning meetings are a team approach to developing a plan of care. Goals are developed to address health problems found on assessment once the nurse has completed the analysis phase of the nursing process, which leads to nursing diagnoses.