Documentation- guidelines, normal/abnormal findings, abbreviations

Accurate documentation entails including essential information that will allow me to easily know what I need to follow-up on with my patient. It also allows for any other practitioners seeing my patient and viewing my notes to understand the plan of care. Documentation guidelines include the patient’s present illness, past medical history, family and social history, review of systems, and functional health patterns. In the physical exam, normal and abnormal findings will be obtained. Clustering the data helps to develop a problem list. SOAP notes serve as a guideline for documentation which stands for subjective, objective, assessment, and plan. The plan includes diagnostic testing, educational approach, and plan for follow-up (Dunphy, 2015)

Documentation serves as protection for the practitioner should there be legal proceedings. If a patient follows or does not follow a treatment plan, this needs to be written. Charts will also be audited by insurance companies to ensure that billing was justified. If the practitioner and patient disagree on a treatment plan, this needs to be documented in a nonjudgmental way. It should occur immediately after the visit (Dunphy, 2015).

Hospitals have an approved abbreviation list; however, they should never be used in patient materials or documentation. This increases the risk of patient misunderstanding and error. The Joint Commission Organization has a list of do-not-use abbreviations (Joint Commission International, 2018).

Clinical reasoning skills- demonstrating, planning the organization of the comprehensive exam

Research shows that it is unclear how practitioners learn clinical reasoning skills, how to teach it or assess for it. Using virtual patients (VP) is one way to learn clinical reasoning in a controlled and safe environment. Concept mapping is another way for the learner to document the clinical reasoning process in the categories of problems/findings, differential diagnoses, tests, and treatments. According to these authors, making a correct diagnosis on the first attempt is the most accurate measure of clinical reasoning competence (Hege et al., 2018). We have used Shadow Health in our Advanced Assessment class and now we will use i-Human in a more advanced format for clinical reasoning.

Factors influencing appropriate tools & tests for a comprehensive assessment

One of the most important factors in determining which tools and tests to use to assess my patient is to know my patient well by caring for them in a holistic manner, physically, mentally, and spiritually. This would mean being sensitive to casual comments the patient may make about a health concern. It is important not to over-rely on lab and diagnostic testing to confirm a diagnosis unless necessary. The physical exam enhances contact with the patient and is a crucial component in reaching a diagnosis (Dunphy et al., 2015).

Utilizing the United States Preventive Services Task Force (USPSTF) Guidelines will assist with screening recommendations for specific patients (Dunphy et al., 2015)

Reflection of personal strengths, limitations, beliefs, prejudices, values/ impact on comp history

My personal strengths, beliefs, prejudices, and values should not impact my ability to obtain a comprehensive history. I have been a nurse for 25 years and learned early on to focus on the patient and not allow any personal feelings to interfere with the care I provide. Any areas of limitation, I will strive to improve upon in the next year.

Utilizing Leininger’s Transcultural Nursing Theory is to incorporate cultural needs and beliefs appropriate to the patient. Examples for the nurse include being respectful and open-minded. Assessing for self-efficacy, communication patterns, perceptions of health and illness, space and time orientation, and family dynamics will ensure we are providing culturally competent care (Burke, 2019).

Develop communication skills, empathy

As nurses, we have already developed communication skills when caring for patients. Some important things to ensure we follow include keeping the visit patient-centered. Nonverbal skills include leaning forward, nodding as the patient is speaking, and making eye contact, as culturally appropriate. Screen gazing has a negative impact on the visit and has been shown to decrease the extent to which we can connect emotionally with the patient. Both empathy and good verbal communication help to enhance the provider/patient relationship, the patient’s willingness to follow the practitioner’s advice and more likely to adhere to the treatment plan (Wright, 2016).

Interview techniques to obtain subjective data, follow up questions to evaluate condition, patient education

Interview techniques can include verbal methods such as open-ended questions, clarifying, and rephrasing. Nonverbal methods include attentiveness, openness, active listening, and empathizing (Hashim, 2017). I personally like using the “OLDCARTS” mnemonic to get as much information as possible about the present illness, which is subjective data. Objective data includes the nurse’s observations utilization the senses of seeing, hearing, feeling, and smelling.

Important follow-up questions would include the patient’s current status if they are experiencing any side effects from new medications or treatments if they are taking them as prescribed, and if their symptoms have improved. The “OLDCARTS” mnemonic can be used again for the follow-up.

Patient education will stem from a management plan developed with the provider and the patient’s goals. With the patient’s input, and ability and desire to follow a treatment plan, they will achieve positive results. A written plan for the patient including follow-up should also be documented in the medical record (Dunphy et al., 2015).

Burke, Alene. “Cultural Awareness and Influences on Health: NCLEX-RN.” Registered,, 17 July 2019,…

Dunphy, L. M. H., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care: the art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F.A. Davis Company.

Hashim, M. Jawad. “Patient-Centered Communication: Basic Skills.” American Family Physician, 1 Jan. 2017,

Hege, I., Kononowicz, A. A., Kiesewetter, J., & Foster-Johnson, L. (2018). Uncovering the relation between clinical reasoning and diagnostic accuracy – An analysis of learner’s clinical reasoning processes in virtual patients. Plos One, 13(10), e0204900.

Use of Codes, Symbols, and Abbreviations (2018)

Wright, B. L. (2016). Communication Skills : Challenges, Importance for Health Care Professionals and Strategies for Improvement. Hauppauge, New York: Nova Science Publishers, Inc. Retrieved from


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