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How to Document Your Patient Assessments

How to Document Your Patient Assessments

Kathy Quan

The Case Description:

Mr. James is a 57 year old gentleman admitted to room 224A two days ago for dehydration secondary to nausea and vomiting for three days. His sclera is slightly yellowed and his abdomen is distended and tender to palpation especially in the upper right quadrant. After two days of IV lasix therapy, he has 2+ edema in his lower extremities to the mid calf. (At admission he had 4+ edema up to the knee.) He complains of mild shortness of breath with moderate activity which he has experienced for several weeks. He has a history of alcohol abuse for 20 years, but denies any use for the past 6 months. He has no history of hepatitis or HIV. No history of drug abuse.

At 7:45 AM, Mr. James is complaining of increasing nausea. He has had no emesis for at least 5 hours, but feels (and fears) the need to vomit is becoming imminent. His last dose of anti-emetic (Tigan) was given at 4:30 AM and he states “it only slightly relieved the nausea this time.” It let him sleep for about two hours, but now he’s “wide awake and very uncomfortable.”

The orders for the Tigan are 200 milligrams (2ml)IM QID (four times a day), and is scheduled every six hours. It has only been a little over three hours since the last dose and is not due again until 10:30 AM. You tell him you will have to contact the MD for orders for something else. Mr. James is reluctant to have you do this and thinks that if he can wait about 30 minutes, the MD is likely to be making his morning rounds. Mr. James wants to try to wait. He thinks he “can control the urge to vomit more it if he can get more comfortable in the bed.”

A quick assessment of vital signs and his body systems reveals no change in condition. In assessing Mr. James, you determine that measures which usually help him to reduce his nausea include using a cold cloth on his forehead and one on the back of his neck. He is usually more comfortable lying on his left side, but is on his right side now because he’s trying to comply with the need to alternate the pressure on his skin. It has been about an hour that he’s been on his right side. Turning can increase his nausea, but doing so slowly may be OK. You assist him to slowly turn and find a more comfortable position. You place the cold cloths on his forehead and the back of his neck, and he reports feeling “much better already.” Slow deep breaths also help him to relax, as well as minimizing distractions such as the TV, lights and closing the door to the room. Pulling the curtains around his bed further isolate him and allow him to relax and concentrate on his slow breathing. In a few minutes he is sleeping.

How do you document your assessment and intervention?

No matter what type of charting your facility uses from checklists to full narrative discussions, you need to be sure to include the most important details. To tell the complete story accurately, you need to include “the 5 w’s and an h.” These are the Who, What, When, Where, Why and How.

There may be more than one way to answer or interpret these questions, but let’s examine one way.

The Who: Mr. James in 224A The What: the increased nausea and fear of imminent emesis

The When: began with the fact that the last dose of Tigan did not completely relieve the nausea

The Where: Mr. James lying in his bed on his right side (to alternate the pressure on his skin)

The Why: the nausea is presumed to be due to an exacerbation of his cirrhosis but it’s unclear why the Tigan was ineffective this time. The patient states he thinks “lying on my right side is so uncomfortable that I can’t relax and let the medication work.” [Use patient quotes for subjective details.]

The How: the intervention: [include the VS and assessment findings] No apparent significant change in condition noted. At this time, patient requests to try other measures and to wait for MD assessment before requesting additional medications. Assisted patient to turn slowly to his left side without incident. Placed cold cloths on his forehead and back of his neck as requested. Patient reports feeling immediately “much better.” Reduced outside stimuli including turning off the TV, turning off the lights, closing the door and drawing the curtain around the bed. Patient performed deep breathing and relaxation techniques as instructed. Patent able to fall asleep within 5 minutes without further c/o nausea and no vomiting. Expect MD to make rounds within the hour.

Whatever the format for your documentation, if you can make simple notes for yourself as to the who, what, when, where, why and how and make sure that you have included all of this information in your charting then you will have accurately and adequately documented the episode.

TIP: Use patient statements to define subjective aspects. You could assume that because he was uncomfortable he wasn’t able to relax and that it contributed to his increasing nausea, but it is best to quote the patient in such matters. Otherwise state only the facts and what you observe.

This article was originally published on The Nursing Site.

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