Documenting HELP!!!

classicdame, MSN, EdD · Sep 17, 2012

read your syllabus again. There may be guidance there. WIthout knowing anything about your course requirements I would GUESS that you can assume you are doing a full assessment in a hospital setting. Sounds like you are making up the findings. How long was the hemorrhoid? Internal or external? Where? Bleeding or not? What has pt said about pain, diet, history of this-------?

metal_m0nk, BSN, RN · Sep 17, 2012

A written narrative is a written account of events. Your instructor wants you to describe how you performed your assessment. What did you do? In what order? What did you find along the way? Were your findings normal or abnormal? She doesn't just want you to write down your findings. If you performed the assessment you are expected to narrate, you should have already collected and written down your raw data (heart rate and tones, respiratory rate, orientation, bowel sounds, etc). You will want to include that data into your narrative, but that should not be the bulk of it. It should go something like, "I began by palpating the head and neck, noting any structural abnormalities and found none. I moved on to assess pupillary response and diameter. Pupils were equal, round, reactive to light and accommodating. Pupil diameter was 3mm and equal. I inspected the oral mucosa for color, moistness, and presence of lesions....etc., etc."

nurseprnRN, BSN, RN · Sep 17, 2012

I have to document a head to toe physical assessment narrative for class. I don't know if my professor wants me to pretent I am at a hospital or what? I do not have a pulse oximeter to do oxygen saturation! Also, When assessing the peri-area my patient has a little hemorrhoid. How am I suppose to document that? "pt has a little hemorrhoid" I am so confused! lol I have done the assessment but am having trouble as to how I am supposed to document it when I am doing it from home.

Ah, not to belabor the obvious, but when you have an assignment you don't understand-- or a diagnosis, or a medication, or a medical plan of care, or anything else-- the best thing to do is ask the person that wrote it for clarification. This will happen many times in your professional life-- this is how you learn to deal with it. Did you ask your professor?

Esme12, ASN, BSN, RN · Sep 18, 2012

Usually you do not document in the first person......"I" What is the assignment say? What is the example that the teacher gave you?

allnurses Guide · Sep 18, 2012

Ah, not to belabor the obvious, but when you have an assignment you don't understand-- or a diagnosis, or a medication, or a medical plan of care, or anything else-- the best thing to do is ask the person that wrote it for clarification. This will happen many times in your professional life-- this is how you learn to deal with it. Did you ask your professor?

Best advice you can get as a nursing student. If you are unsure, research it and if our are still unsure, ask an appropriate person.