• What does it mean to document accurately and appropriately?

All nurses know the phrase, “if it’s not documented, it didn’t happen.” Documenting appropriately and accurately ensures one provides the right care in addition to keeping ourselves accountable and legally responsible. It can also be considered a form of communication. Anyone from the multidisciplinary team should be able to pull a patient’s chart and see the treatment they received. According to Selvi (2017), documentation is an important part of nursing practice. It is a tool of professional practice and one that should help the care process.

• What are the documenting guidelines? When is it appropriate to use abbreviations?

Documentation should always be clear, timely, and accurate. According to the American Nurses Association, there are six nursing documentation principles. (Documentation Characteristics, Education and Training, Policies and Procedures, Protection Systems, Documentation Entries and Standard Terminologies.) ‘Documentation Characteristics’ describes what quality documentation entails. It is accessible, accurate, consistent, relevant, complete, clear, legible, thoughtful, timely, and reflective of the nursing process. ‘Education and Training’ is defined as completing training to understanding and gaining full access to the computer, software system and the documentation system. ‘Policies and Procedure’ is defined as being aware of and understanding the policies and procedures put in place at one’s institution having to do with documentation. ‘Protection Systems’ is defined as protecting the patient, securing all forms of data, and maintaining confidentiality. ‘Documentation Entries’ is defined as keeping health records organized and accessible. It is vital to date and time-stamp all entries and all entries are made using proper terminology including acronyms and symbols. Lastly, ‘Standardized Terminologies’ is using terms that are appropriate when explaining the planning, delivery, and evaluation of care given to the patient. Selvi (2017) listed a few documentation guidelines. To name a few, one must ensure they have the correct patient’s chart. One must date and time each entry. One must never change another person’s entry even if it is incorrect. One must use quotation marks to indicate a direct patient response. One must use permanent black ink. One must document in chronological order. Lastly, one must document all telephone calls made or received regarding a patient’s care.

• What is the difference between subjective and objective data?

Subjective data is the information one receives from the patient. It is to be documented in the patient’s own words. Objective data is information we obtain by observing and assessing the patient in completing a physical exam.

• What does it mean to demonstrate clinical reasoning skills?

Clinical reasoning skills is having the ability to use the knowledge one has gained and applying it successfully and appropriately. As a nurse, this skill helps you assess, diagnose and treat patients with confidence. According to Passos Vaz da Costa and Barros Araújo Luz (2016), using clinical reasoning allows nurses to makes judgments about the clinical condition of the patient.

• How can you use clinical reasoning to plan the organization of a comprehensive exam?

Organization is key in nursing. When assessing a patient it helps to maintain the flow of an exam. It will aid in making the proper diagnosis and in certain situations the difference between life and death. Assessing the patient from head-to-toe and understanding how certain things connect and intertwine. Knowing what to look for or what exams to order when a patient is experiencing certain symptoms is thinking critically and clinically. According to Lavin, Harper, and Barr (2015), using the nursing process model will help standardize and improve communication of direct care.

• How will you document variations of normal and abnormal assessment findings?

Documenting normal findings is just as important as documenting abnormal findings. This is where the organization is key. As you are completing your head-to-toe assessment of the patient, you should be documenting everything that has to do with the specific body system. Using the four techniques taught and charting as we assess has proven to help tremendously.

• What factors influence the appropriate tools and tests necessary for a comprehensive assessment?

Nurses know different tools are used for different body systems. If we examine a specific body part or want to further explore a complaint or symptom we must use specific tools, tests, imaging, or exams. We know when an x-ray versus an MRI is needed. We know what a tuning fork is and how and when it should be used and what a negative versus a positive finding is. Nurses also know when it’s necessary to ask for a urine sample or a blood test and what to check the results for depending on the age or sex of the patient.

• Reflect on personal strengths, limitations, beliefs, prejudices, and values.

I know what my strengths and limitations are and it’s smart to know and acknowledge when you don’t know something and that you need help. I know to check my prejudices and not to allow them to affect the care I give. I may not agree or understand why a patient made a specific decision about their care, but I have to respect it. With that said, I also have to know what I value and belief and stand strong in those values. My patient’s values may not be my values, but we can all coexist, learn from each other and treat each other as human beings.

• How will these impact your ability to collect a comprehensive health history?

My strengths give me the confidence to complete health history. Knowing my limitations lets me know when it is time to refer an individual and reach out to the multidisciplinary team. Standing firm in my values and beliefs allows me to know how far I would go in treating a patient and what I allow myself to be exposed to while empathizing with patients and their families and understanding their points of view.

• How can you develop strong communication skills?

Developing strong communication skills does not happen overnight. I practice in the mirror and set up mock interviews. Listen to individuals and think about your response before you respond. Demonstrate confidence by maintaining eye contact and have proper body language.

• What interviewing techniques will you use to interview the patient to elicit subjective health information about their health history?

To obtain subjective data, one must approach the patient calmly and respectfully. Asking open-ended questions will open the door for dialogue and allow the patient to disclose information. Maintaining eye contact and taking the time to acknowledge what they’ve said will let the patient know you are listening and engaged.

• What relevant follow-up questions will you use to evaluate patient condition?

The keyword here is relevant. Depending on the complaint and symptoms, questions should be asked. For example, we know when a patient complains of headaches to ask…The onset of headaches? The duration of headaches? What relieves it? What makes it worse? All these questions are relevant and necessary and will guide the nurse in providing the best treatment.

• How will you demonstrate empathy for patient perspectives, feelings, and sociocultural backgrounds?

First and foremost, you have to respect the patient. You are there to provide quality care to the individual regardless of their appearance, level of education, class, or beliefs. As I said before, listening to the patient’s needs and acknowledging the patient’s perspective will go a long way. According to Kerfoot (2019), having compassion gives us the ability to suspend stereotypes and see the human being.

• What opportunities will you take to educate the patient?

I will take any and every opportunity to educate the patient. It may be a suggestion in diet, encouraging the patient to continue their workout regimen, demonstrating proper handwashing techniques, addressing concerns about a medication, how to read and understand their lab results or what to expect during a procedure.

References

Kerfoot, K. M. (2019). Chaos, teamwork, compassion, and leadership: Disasters and nursing’s finest hours. Nursing Economic$, 37(5), 265–267. Retrieved from https://search-ebscohost-com.libauth.purdueglobal.edu/login.aspx?direct=true&db=rzh&AN=139009319&site=ehost-live

Lavin, M. A., Harper, E., & Barr, N. (2015). Health information technology, patient safety, and professional nursing care documentation in acute care settings. Online Journal of Issues in Nursing, 20(2), 6. https://doi.org/10.3912/OJIN.Vol20No02PPT03

Passos Vaz da Costa, C., & Barros Araújo Luz, M. H. (2016). Nursing scientific production on diagnostic reasoning: Integrative review. Journal of Nursing UFPE / Revista de Enfermagem UFPE, 10(1), 152–162. https://doi.org/10.5205/reuol.8423-73529-1-RV1001201620

Selvi, S. T. (2017). Documentation in nursing practice. International Journal of Nursing Education, 9(4), 121–123. https://doi.org/10.5958/0974-9357.2017.00108.8