Bedside Assessment and Documentation Basics: A Pocket Card for Beginning Nursing Students

Submitter Information

Author: Angela D. Jones, DNP, RN
Title: Assistant Professor, School of Nursing
Institution: Stephen F. Austin State University
Email: jonesas7@sfasu.edu

Competency Category(s)
Informatics, 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

Skills –Use appropriate strategies to reduce reliance on memory (such as, forcing functions, checklists).

Attitudes –Appreciate the cognitive and physical limits of human performance.

Value vigilance and monitoring (even of own performance of care activities) by patients, families, and members of the health care team.

Knowledge – Identify essential information that must be available in a common database to support patient care.
Skills – Document and plan patient care in an electronic health record.

The student will use the Bedside Assessment and Documentation Basics pocket card in clinical practice (actual human patients and simulation) to facilitate the process of assessment explicit to the needs of the patient(s).

The student will document the findings of the bedside assessment in clinical practice (actual human patients and simulation) in a clear and concise manner using the Bedside Assessment and Documentation Basics pocket card as a guide to promote communication of findings to other members of the interdisciplinary team.

The student will use the Bedside Assessment and Documentation Basics pocket card in clinical practice (actual human patients and simulation) to reduce reliance on memory.

Strategy Overview

The Beside Assessment and Documentation Basics: A Pocket Card for Beginning Nursing Students is a clinical tool to promote quality, safe care in beginning nursing students. First semester pre-licensure nursing students are challenged to acquire and develop the essential knowledge, skills, and attitudes necessary for basic patient care. This beginning educational experience is often stressful as students are required to integrate fundamental concepts and health assessment strategies in clinical practice during a relatively short period of time.  In addition to the stress response of the students, faculty are met with the challenge of ensuring students perform quality, safe care while focusing on the patient and adequately communicating the patients’ needs to other members of the interdisciplinary team.

In an effort to promote patient safety by minimizing student anxiety and omissions in assessment data collection, students are provided with the Bedside Assessment and Documentation Basics pocket card for use in the first clinical course. The Bedside Assessment and Documentation Basics pocket card is intended for student use with each clinical experience (actual human patients, laboratory, and simulation). The pocket card serves as a reminder of the essential components included in a basic bedside assessment and facilitates building a common database for documentation needs. The information contained on the card is common to nursing practice and has been adapted to meet the learning needs of the novice student.

First semester pre-licensure nursing students are beginning to develop a working knowledge base along with the necessary skills associated with health assessment. By providing students with the pocket card, this decreases reliance on memory for patient assessment in students who are developing a clinical knowledge base. Clinical forms and clipboards often become a barrier to communication as students search for the appropriate form or space in which to document their findings rather than focusing on the patient. The pocket card decreases dependence on a vast array of clinical documentation forms at the bedside; however, students are encouraged to take notes regarding their assessment findings. The pocket card does not replace clinical documentation as defined by individual programs of study but facilitates translation of the students’ assessment data to meet the documentation requirements by fostering clear, concise communication among members of the health care team and assists with documentation in the electronic health record (EHR). Using the Bedside Assessment and Documentation Basics pocket card with beginning nursing students facilitates quality, safe patient care while fostering the use of informatics.

Directions for use

The Beside Assessment and Documentation Basics: A Pocket Card for Beginning Nursing Students 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 and used throughout the fundamental course.

 

Student Instructions:
Bring the card with you to all clinical experiences (lab, simulations, or actual patient clinical rotations).
Use the pocket card to help guide your bedside assessment. This is to remind you of required components with each system. This promotes patient safety by reducing reliance on your memory.
The pocket card also functions to remind you of essential information that must be included in the EHR to support patient care. This information is common to nursing practice and addresses basic documentation requirements.
Make clear and concise notes regarding your assessment findings. By using the pocket card as a reminder of assessment needs, this keeps you from flipping through papers searching for necessary information so that you maintain focus on the patient.
Use your notes to assist with your clinical documentation when you are away from the bedside entering the data in the EHR (as assigned by faculty). This aids in communication of assessment findings and ultimately promotes quality, safe patient care.
Using the pocket card will also assist you in communicating with members of the health care team as you learn to gather data and share your insight regarding patient assessment (verbal and written).

Submitted Materials

QSEN-Bedside-Assessment-Pocket-Card-Revised-2.doc
QSEN-Bedside-Card-Revision-01-26-16-1-1.doc
QSEN-Bedside-Assessment-Pocket-Card-Revised-3.doc

Additional Materials

Evaluation Description

When evaluating the effectiveness of the Bedside Assessment and Documentation Basics pocket card, it was noted that required clinical documentation had improved after implementation. Students had fewer assessment omissions and were able to articulate their assessment findings using appropriate terminology. Student reflection regarding their perception of using the pocket card in clinical is an effective strategy for evaluating the effectiveness of the pocket card with regard to promoting safety, valuing their contributions to patient care, enhancing communication, and facilitating documentation in the EHR.

Data collected from students’ reflections of fundamental nursing experiences revealed an enhanced level of comfort in the clinical course associated with bedside assessment, documentation requirements, and communication. The pocket card was not required for lab or simulation at the beginning of the pilot semester, though it was incorporated as students asked to use the pocket card in simulated experiences to minimize personal anxiety. Improvement in performance was noted as students made fewer omissions in gathering assessment data when using the pocket card. Overall, using the Bedside Assessment and Documentation Basics pocket card in clinical has promoted quality, safe patient care while improving clinical documentation and communication.

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