Admission Health History: Assessment Pocket Card

Submitter Information

Author: Angela D. Jones, DNP, RN
Title: Assistant Professor
Institution: Stephen F. Austin State University
Email: jonesas7@sfasu.edu
Coauthors: Savana Eaton, SFASU Student Nurse

Competency Category(s)
Informatics, Patient-Centered Care, Safety

Learner Level(s)
Pre-Licensure ADN/Diploma, Pre-Licensure BSN

Learner Setting(s)
Clinical Setting, Skills or Simulation Laboratories

Strategy Type
General Strategy

Learning Objectives

1) Patient-Centered Care:
a. Skills- 1) Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care.
b. Attitudes – 1) Value the patient’s expertise with own health and symptoms.
2) Safety:
a. Skills – 1) Use appropriate strategies to reduce reliance on memory (such as, forcing functions, checklists).
b. Attitudes – 1) Appreciate the cognitive and physical limits of human performance. 2) Value vigilance and monitoring (even of own performance of care activities) by patients, families, and members of the health care team.
3) Informatics:
a. Knowledge – 1) Identify essential information that must be available in a common database to support patient care.
b. Skills – 1) Document and plan patient care in an electronic health record.

Strategy Overview

The Admission Health History: Assessment Pocket Card is clinical tool that was collaboratively developed by an undergraduate nursing student and faculty member. This tool is intended to promote quality, safe, patient-centered care in beginning nursing students as students seek to gather the patients’ health history information. As first semester nursing students are developing their nursing knowledge and skills, it is imperative to offer guidance in the clinical setting (laboratory, simulation, and actual human patient care).
Students are challenged to apply concepts from the classroom to clinical practice which can be overwhelming and stressful at times. In an effort to promote the highest quality patient care along with valuable student learning experiences, a pocket card was developed to meet the needs of the learner while fostering comprehensive assessment data collection. The Admission Health History pocket card is intended for beginning nursing student use with each clinical experience (actual human patients, laboratory, and simulation) serving as a reminder of the essential components included in a basic patient health history. The information contained on the pocket card is common to nursing practice and meets the learning needs of a first semester fundamental student. It is also congruent with simulated electronic health records commonly used by many nursing programs.
By providing first semester pre-licensure nursing students with the Admission Health History pocket card, this clinical tool reduces reliance on memory and promotes communication of relevant health history information between the patient, student, and medical team. This tool is to be used in conjunction with clinical documentation as required by individual nursing programs. The information gained from interviewing the patient based on the cues provided by the pocket card can then be transferred to the electronic health record (EHR) fostering the use of informatics.
Directions for use:
The Admission Health History: Assessment Pocket Card is printed on card-stock paper and laminated for student use in all clinical settings (actual human patients, laboratory, and simulation). The pocket card will be given to students at the beginning of the first clinical course for use throughout the semester.
Student Instructions:
– Use the pocket card to help guide your health history interview. This promotes patient centered care as you elicit responses from the patient valuing their experiences and expertise. It also reduces reliance on your memory which promotes safety and comprehensive assessment. The pocket card serves as a reminder of essential health history information that must be included in the simulated EHR to support care plan development and implementation.
– Make notes regarding patient’s statements about their health history maintaining your focus on the patient. You will use these notes when entering the data in the simulated EHR as assigned. You will also need to report your findings to the patient’s primary nurse and to your instructor if your findings are not congruent with or are in addition to information gained during report. This facilitates quality, safe, patient-centered care.

Submitted Materials

Admission-Health-History-Pocket-Card-QSEN-2018.doc
Strategy-Info-Admission-Health-History-Pocket-Card-QSEN-2018.docx

Additional Materials

http://qsen.org/bedside-assessment-and-documentation-basics-a-pocket-card-for-beginning-nursing-students/

Evaluation Description

The Admission Health History pocket card was implemented by one clinical cohort and found to be useful in gathering more specific and comprehensive health history. There were fewer gaps in essential data collection and documentation. Anecdotal evidence supports the use of this tool in developing a knowledge base of patient health history information. Furthermore, this tool was used in conjunction with the Bedside Assessment and Documentation Basics pocket card that is also published on the QSEN website providing a comprehensive approach to patient assessment in beginning nursing students.