Esther Park is a 78- year-old patient in Shadow Health Simulation who presents with abdominal discomfort, constipation and related symptoms. Thorough documentation by the nurse in assessments like hers is essential in real-world nursing practice to ensure accuracy and support clinical decision making. To achieve this, best practices noted during assessment of Esther Park will be discussed in this clinical essay.
Tips For Efficient Documentation.
- Use a Systematic Approach: During the assessment, follow a head-to-toe approach when documenting objective data. This ensures consistency in documentation and as a result prevents rumbling narratives and ensures critical elements are covered. For instance, when documenting Esther Park’s objective data, it important to start with the affected system (Gastrointestinal system) then move back to the HEENT followed by the respiratory system in a head-to-toe approach.
- Document in Real Time: Record your finding as you assess your patient to reduce reliance on memory which improves the overall accuracy when delivering diagnoses. For example, note how low fluid and fiber intake correlates with palpable fecal mass to prioritize constipation over other causes of the abdominal pain during Esther Park’s assessment.
- Be Specific and Objective: Always use clear, concise language when documenting your findings. The nurse can also use short phrases in the EHR where possible and include only relevant findings. For instance, “ BP 120/80 mm Hg” since she is hyperactive.
- Focus on Relevant Data: Document the patient’s key elements for efficiency. Always start with establishing the Chief complaint first, followed by a systematic assessment. For instance, when starting to record your subjective findings you can start by indication. “Patient reports of dull, lower abdominal pain rated 6/10, worsened over 2-3 days; no bowel movement in 5 days; low fiber/fluid intake.”
- Use Templates and EHR Tools: Utilize the use of auto-populated templates for vitals, exam and care plan present in digital systems like Shadow Health. Follow the facility guidelines to remind you of the key questions necessary during the Simulation without extra note-taking.
Conclusion.
Practicing in adult Simulations like Esther Park helps the student nurse to build confidence and deliver accurate diagnoses and care plans to their patients . In real-world clinical practice, , these skills are useful since they help nurses identify all the relevant information during objective and subjective data collection to help come up with a diagnosis and care plan, hence improving patient outcome.
