Assignment – Narrative Documentation

Background

Clear, accurate documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation communicates clinical information about the clients health that is shared with the interdisciplinary team to ensure continuity of care.

In this assignment you will completed the Shadow Health focused assessment module and apply/record findings to a narrative documentation. You may complete the Shadow Health module as often as you wish until you are satisfied with the results.

Expectations for your documentation assignment will need to align with Norquest Documentation guidelines and expectations.

Please review the Marking rubric attached below as an additional guide to documentation expectations. ALL documentation is required to be completed on the Shadow health platform. Please do not submit a word/ pdf version of documentation to this dropbox.

Instructions.

Please review the instructions and the marking rubric thoroughly.

You MUST choose one of the following focused systems from the list below.

The patient Assessed should be Tina Jones

HEENT

Respiratory

Cardio

Abdominal

Musculoskeletal

Complete the Shadow Health focused assessment of your choice from the list identified above. This should include the following.

Date and Time in the correct format.

Vital Signs, (these will be documented on the Shadow Health Electronic Flow sheet)

Client safety components (for beginning and end of assessment)

Level of Consciousness and Orientation to all four spheres. (Person, Place, Time and Self)

Assess Allergies (Environmental, Medication, and Food) AND the reaction.

Pain (OPQRSTUV) . Regardless of the system assessing, document the pain reported by the patient.

Documentation of minimum 4 subjective AND 2 follow up question for the chosen focused system. (exclude pain in this portion)

HINT: Your Jarvis textbook is an excellent guide.

Objective assessments

Inspection

Palpation

Auscultation OR Specialized assessments (this would include HEENT, or MSK)

Health promotion.

There are marks allotted for the DCE score achieved on Shadow Health module completed.

This is identified when you upload the LAB PASS to moodle.

You may repeat on the Shadow Health platform as often as you wish until you are satisfied with your assessment score. (See rubric attached)

HINT: The more comprehensive your assessment is, the easier it will be to document.

Once you are satisfied with the focused system assessment of your choice.

Document vital signs electronically on Shadow Health

Complete narrative documentation on your assessment finding (subjective and objective) and health promotion teaching on the shadow health nursing progress notes.

You will be expected to document as per Norquest documentation guidelines. (See marking rubric)

Narrative notes must be specific using appropriate medical terminology.

Do not use vague words like “normal, good, or no abnormalities”. Describe what you did find.
Do not use abbreviations. ( eg. LOC , Orientation X4, or SOB)

We will not accept a word version of narrative client care record submission.

Shadow health records a transcript of your assessment as a tool that can be used to assist with your documentation. (This is also available for your instructor to review if required.)

When you are satisfied with the results, download your Lab Pass and submit to the Documentation Drop box on Moodle. (The Lab pass is the only acceptable document that will be accepted in the drop box).

See attached on Moodle for instructions on how to download the Shadow Health lab pass.

Submission of the lab pass acts as notification for your instructor that your documentation on the Shadow Health platform is ready for grading. The lab pass also provides the instructor with the following grading information:

Which system you completed documentation

And which Shadow Health attempt should be graded. ( Date and Time)

Your instructor will log into Shadow Health and will grade your documentation after the Lab Pass is submitted. Feedback on your documentation will be provided by your instructor on moodle.

If you have any questions, please reach out to your theory instructor.