HA3004 Comprehensive Health History Assessment

Overview

For this Performance Task Assessment, you will complete a comprehensive health history on a simulated patient in the Shadow Health platform.

Submission Length: Conduct a 3-hour comprehensive health history using Shadow Health software. As you complete the steps necessary to conduct a comprehensive health history, you will also document your progress in Shadow Health.

Instructions

To complete this Assessment, do the following:

Complete the Digital Clinical Experience (DCE) Orientation and the Conversation Concept Lab by Achieving a “Lab Pass”

  • Review the instructions that you are given when you log in to Shadow Health.
  • Review the Assignment Overview for the Health History Assignment in Shadow Health.
  • Review the Objectives and Instructions for the Health History in Shadow Health.

You are the nurse providing care for Tina Jones as part of her admission to Shadow General Hospital. Ms. Jones was admitted to the ER for a painful foot wound. After completing your patient interview, you will identify and prioritize potential nursing diagnoses for Ms. Jones. You will then develop plans to address your diagnoses.

In Shadow Health, complete the following:

  • Perform the comprehensive health history in Shadow Health.
  • Be sure to document your engagement with Tina Jones as you perform the comprehensive health history in Shadow Health.
  • Obtain a Lab Pass and a copy of your documentation of the comprehensive health history for submission for this Assessment.

Before submitting your Assessment, carefully review the rubric. This is the same rubric the SME will use to evaluate your submission and it provides detailed criteria describing how to achieve or master the Competency. Many students find that understanding the requirements of the Assessment and the rubric criteria help them direct their focus and use their time most productively.

Rubric

All submissions must follow the conventions of scholarly writing. Properly formatted APA citations and references must be provided where appropriate. Submissions that do not meet these expectations will be returned without scoring.

This Assessment requires submission of two files: one file containing your “Lab Pass” and a separate file containing the saved documentation from the Health History Assessment.

Save your “Lab Pass” as a PDF file. It should be labeled as HA3004_labpass__firstinitial_lastname (for example, HA3004_labpass_J_Smith).

  • Save your Health History documentation as a Word document. It should be labeled as HA3004_documentation_firstinital_lastname (for example, HA3004_documentation_J_Smith).

When you are ready to upload your completed Assessment, use the Assessment tab on the top navigation menu.

Important Note: As a student taking this Competency, you agree that you may be required to submit your Assessment for textual similarity review to Turnitin.com for the detection of plagiarism. 

All submitted Assessment materials will be included as source documents in the Turnitin.com reference database solely for the purpose of detecting plagiarism of such materials. Use of the Turnitin.com service is subject to the Usage Policy posted on the Turnitin.com site.

Health Assessment Nursing Documentation

In each of the Shadow Health (SH) exams you will be asked to complete a narrative note as part of the grading criteria. Narrative or progress notes are often a new skill for nurses. This document is provided to assist students in understanding how to write a narrative nursing note. Shadow Health refers to these notes as Shift Assessment or Nursing Progress Note.

Documentation of patient care is essential to quality and safety of care. Much of the clinical documentation is completed electronically using point and click tools to describe the patient condition (Lindo, et al., 2016). Often computer prompts fall short of fully describing the patient’s condition. Other situations such as lack of technology, electrical outages, system hacking, failure of equipment, and any number of situations which may interfere with normal electronic documentation may require a narrative nurses/progress note. Nurses must be able to clearly communicate patient information with everyone on the health care team to ensure quality and safety of care (Lindo, et al., 2016).

Documentation must be clear, paint a picture of the patient, and provide measurable concise information in a timely manner. The information communicated must be able to be understood by others and provide enough information to understand if a change has occurred in the patient’s condition and to clearly communicate all treatments, interventions, and therapies received by the patient and/or planned for the patient. Documentation also serves as a legal record of care (Lippincott Williams and Wilkins, 2007).

Documentation begins with subjective data/information. This is information the patient, family member, or caregiver may provide if the patient is unable to communicate which includes such data as the history of present illness (HPI), the past history- medical surgical & social and the review of systems (ROS). Objective data/information includes the physical exam, observations and measurements obtained during the examination of the patient. Objective data also includes vital signs, laboratory and diagnostic results (Jarvis, 2016a).

Data gathering begins with subjective data followed by the objective data and progresses in a cephalocaudal, meaning head to toe, format. Objective data will also be documented in a cephalocaudal manner and in order of the assessment techniques inspection, palpation, percussion, and auscultation. 

The assessment technique order is important and only varies for the abdominal assessment and in special circumstances such as patient condition and ability to move or follow direction (Jarvis, 2016a). Note, the Narrative Note, Nurses Note, or Shift Assessment is to contain headings for each body system being assessed. The assessment skill being used is not generally named or used for organizing the note. See the examples below for reference.

Subjective information assists in understanding the patient’s condition and provides a basis upon which the nurse decides which body systems need to be assessed and which assessments need to be completed. Many of the assessments to be performed in the class are focused or problem based and focus on the assessment of a specific body system. The Comprehensive assessment is a complete health history and physical exam of most all body systems (Jarvis, 2016b).

Once subjective and objective information are obtained and have been thoroughly considered an assessment/nursing diagnosis or medical diagnosis (physicians and advanced practice only) is identified. A plan of care will then be developed based on the nursing diagnoses. In the health assessment competencies, the primary focus is on gathering accurate subjective and objective data (Jarvis, 2016b).

Subjective data should be recorded using the patient’s own words and describing his/her feelings and experiences related to health. When interviewing the patient about a current issue or illness the eight critical characteristics (CCs) need to be included in the documentation (Jarvis, 2016a). The eight CCs would be asked for any positive response during the health history (HH) and review of systems (ROS). Here is a list of the CCs and a few sample questions for a patient with complaints of abdominal pain (Jarvis, 2016a).

  • Location: “Where does it hurt?” “Please point to the area of pain.”
  • Character or Quality: “How would you describe the pain?” “Is it sharp pain?” “Dull pain?”
  • Quantity or Severity: “On a scale of 0-10, 0 being no pain and 10 being the worst pain ever, what is your level of pain?” “How has the pain impacted your daily routine?”
  • Timing: “When does the pain occur?” “How long does it last?” “Approximately how long after you have eaten does the pain begin?” ”Does the pain radiate?” “If yes, where does it radiate?”
  • Setting: “What were you doing when the pain began?”
  • Aggravating or Relieving Factors: “Is the pain worse after eating certain foods?” “What makes the pain better?”
  • Associated Factors: “Do you have any nausea or vomiting?” “Any diarrhea?” “Any constipation?”
  • Patient’s Perception: “What do you think the pain means?”

Another way to remember what to ask the patient is to use the mnemonic PQRSTU (Jarvis, 2016a, p. 51).

P: Provocative or Palliative

Q: Quality or Quantity

R: Region or Radiation

S: Severity Scale

T: Timing

U: Understand Patient’s Perception

When documenting the ROS it is necessary to document each condition or item asked about because others will be reading the notes and relying on the information provided. If information is incomplete or inaccurate patient safety and quality of care may be affected. It is unacceptable to document: “No problems”, “WNL”, “Negative”, or “No complaints”. These terms do not describe what was assessed, seen, felt, heard, measured, or smelled (Jarvis, 2016a).

ROS (Subjective) Documentation Example:

Review the following ROS areas and the associated documentation and note the quality of the information provided for each system.

  • Skin: Denies any history or issues with eczema, psoriasis, hives, changes in color of skin, changes in moles size or shape, or color, dry skin, open areas/wounds, or excessive moisture. 
  • States does have a red rash on her left wrist, the rash began about a week ago, itches most of the time, some moisture from the rash, denies pain at the site, has tried some Benadryl with some relief, thinks it gets worse after she wears a particular bracelet and thinks it may be related.

Hair: States feels like her hair is “lacking” and explains she thinks it falls out a lot.

Denies change in color or texture. Denies change in shape, color, or brittleness of

nails and adds she has never been able to grow long nails as they seem to be soft and bent.

Head: No problems with head or headaches.

  • yes: No problems, says they are normal.

(Jarvis, 2016c)

Skin and hair are documented correctly, they both provide specific information of the conditions asked and the patient responses. Skin also includes the eight CCs of the patient issue related to a rash on her left wrist. Head and eyes subjective documentation does not contain enough information. 

Another nurse reading this documentation would not know if the patient had been asked about most possible issues related to the head or eyes. Therefore, an incomplete picture of the patient would be obtained. This may lead to rework or incorrect care plans and interventions (Jarvis, 2016c).

Assessment (Objective) Documentation Example:

  • Skin: Uniform in color, tan, warm, dry, intact. Turgor good, skin returns immediately when released. Scattered flat small macules on face around nose.

On the back of the left shoulder 4mm, symmetrical, smooth borders, dark brown, evenly colored, slightly raised nevus, without tenderness or discharge. Well healed pale scar 3 cm right forearm. Left wrist approximately 1 cm area around the circumference of the wrist pruritic papules and vesicles with an erythematous base. Silver colored stripes around lower outer quadrants of abdomen and hips.

  • Nails: normal shape and contour, soft, capillary refill good.
  • Hair: Brown
  • Eyes: Eye color brown. brows, lids, and lashes symmetric, right brow ridge piercing with intact silver hoop, no redness, tenderness, or discharge; lacrimal ducts pink and open without discharge. Conjunctiva clear, sclera white, moist, and clear, no lesions or redness, no ptosis, lid lag, discharge or crusting. Snellen vision assessment 20/20 in each eye with corrective lenses. EOMs intact, no nystagmus, PERRLA (Jarvis, 2016c)

Skin is documented very complete and concise a picture of the patient is evolving and measurable assessment data is provided. Complete description of the rash on the left wrist provides a measurable concise picture. A mole was noted and documentation included the ABCDE of the mole. 

It is important to describe both normal and abnormal findings in a measurable manner. The text offers examples of how to provide measurable information for many assessment findings such as tonsils, pulses, reflexes, and strength (Jarvis, 2016c).

The documentation for nails is less measurable. How does one know what “normal shape and contour” is for this patient? The nails are not described. The shape, contour, profile, consistency, color and capillary refill should be documented. Capillary refill is noted but not measurable. What is considered “good”. A patient with chronic COPD

“good” capillary refill may be greater than 4 seconds and someone without a respiratory “good” may be less than 3 seconds. Terms such as “good”, “fair”, etc. are not measurable and are rarely used in assessment.

The assessment information related to hair only provides the color, no information about texture, distribution, thickness, etc. are provided. These are all important to note.

The documentation for the eyes is very thorough and concise. Measurable terms are used and a description of the patient’s eyes is provided.

Some of the Shadow Health (SH) exams focus on one body system such as Cardiac. In this situation focus on pertinent questions related to the ROS and physical assessment for cardiac and any associated body systems. In the case of cardiac, peripheral vascular and respiratory would be additional systems to assess.

When completing the assessments in SH use the text as a guide. Open to the appropriate chapter and follow along to ensure all aspects of the assessment are covered for both subjective and objective assessment areas. Document carefully for each assessment area keeping in mind the differences between subjective and objective information and ensuring measurable concise information is recorded.

Subjective and objective information is separated and each body system is used as a heading for easier retrieval of information. When information is disorganized it is difficult to know which is the information provided by the patient and which is the objective clinical assessment data. In an emergency retrieval of information must be done quickly. Well organized and written notes allow for timely retrieval (Lindo et al., 2016).

References

  • Jarvis, C. (2016a). Physical examination and health assessment (7th ed.). The complete health history (pp. 49-66). St. Louis, MS: Elsevier.
  • Jarvis, C. (2016b). Physical examination and health assessment (7th ed.). Evidence-based assessment (pp. 1-9). St. Louis, MS: Elsevier.
  • Jarvis, C. (2016c). Physical examination and health assessment (7th ed.). The complete health assessment: Adult (pp. 775-788). St. Louis, MS: Elsevier.
  • Lindo, J., Stennett, R., Stephenson-Wilson, K., Barrett, K.A., Bunnaman, D., Anderson-Johnson, P., Waugh-Brown, V., and Wint, Y. (2016). An audit of nursing documentation at three public hospitals in Jamaica. Journal of Nursing Scholarship, 48(5), 508-516.
  • Lippincott Williams & Wilkins (2007). Charting: An incredibly easy pocket guide. Ambler, PA: Author.