What You Should Put In Your Nursing Assessment Documentation (part 1)

Photo courtesy of Christiana Care (Flickr.com)

Most nurses struggle with what to put on the patient’s chart or with a good working nursing assessment example, especially when it comes to putting assessment data on the nurse’s notes. Nurses often ask themselves where to draw the line between relevant and irrelevant data, and “too much” or “too few” data - and this becomes a source of numerous documentation problems. When the chart lacks substantial data, the nurse finds it difficult to determine a patient’s problem. Consequently the nursing care plan would be inefficient in solving the problem. On the other hand, if the nursing assessment documentation has too much data, it would create confusion for the nurse on how to properly cluster and organize it to come up with a relevant care plan.

With this in mind, it’s time to ask: what should you put in your nursing assessment documentation, to ensure that you would be able to accurately identify a nursing diagnosis and make the necessary plan of care for that diagnosis? While there are numerous ways to make proper documentation, let me share with you a tested framework that can help you achieve accurate and relevant documentation:

1.       Identify the sign or symptom. This is always the first thing to do. Is the client experiencing pain? Fever? Cough? Difficulty walking? A problem with urinating? If you’re going to ask the patient about a symptom, it’s categorized as subjective data, and should be included in the patient’s health history. With subjective data, you should take note of the patient’s verbalizations as he describes it. If you found a sign during a physical exam, you must document the sign with the appropriate term (i.e. ecchymosis, pallor, cyanosis)

2.       Ask about the onset of the sign or symptom. When did it start? Whatever the client states, it would give you an idea of whether the problem is long-term or short-term. It’s not enough to document only “cough” in your nursing assessment documentation. Having knowledge of the onset will also hold a clue to the cause of the problem. A short onset of cough can be caused by a common viral infection, while a cough that started three months ago may be due to chronic obstructive pulmonary disease.

3.       Where’s the symptom located? Is the problem located in a small region of the skin? Does it involve a larger portion, like a limb? Does the symptom occur bilaterally? Do the signs occur on the whole body? Having noted the symptom’s location would hold clues on the characteristics of the disease. Local lesions that progress to systemic lesions over a period of time could tell that the disease is worsening. The location would also tell which part of the body is experiencing a pathological condition. For example, pain felt at the right upper quadrant of the abdomen might be due to a liver or gallbladder disease.

4.       How long has he been experiencing this symptom? Having knowledge of the duration of the problem is equally important; it can determine if the problem is acute or chronic. Acute pain can be attributed to short-term injury or inflammation, while pain that has been occurring for more than 6 months might be a signal for a chronic condition such as cancer.

5.       Let the patient characterize the symptom. Taking note of the character of the symptom on the nursing assessment documentation can significantly improve the way nurses diagnose and treat client responses. A patient who describes an “excruciating” pain on his limbs might be experiencing a fracture. A client who is experiencing a “hacking” cough might be developing lung cancer. A patient who tells that “something kinda gave way” on his operative site might be experiencing wound dehiscence.

Remember that documenting the symptom or sign alone is not enough; you have to know and document the (1) onset, (2) location, (3) duration and (4) character of the sign or symptom. 

Click for part 2 of this discussion.