NURSING DOCUMENTATION WORKSHOP

September 14-15, 2023

Submitted by: JULIE ANN T. BIOL, RN

Scenario 1:
Number 1:
Diane's documentation certainly captures the essential actions she took during her
shift and how Mr. Cruz responded to them. Here is a critique based on the characteristics of
effective documentation, which typically emphasizes clarity, completeness, accuracy, and
relevance.
Strengths:
1. Timeliness: Diane documented the time at which the significant events (medication
administration and dressing change) occurred, which helps in maintaining a
chronological record of the patient's care.
2. Response to Intervention: Diane mentioned how Mr. Cruz tolerated the dressing
change, which is a good practice as it records the patient's response to the nursing
interventions.
Areas for Improvement:
1. Thoroughness:
 The documentation does not capture the pain scale rating before and after
administering the pain medication. Including these values would offer a
clearer picture of the effectiveness of the intervention.
 Diane did not document her observation regarding Mr. Cruz's facial grimacing
and limping, which indicated the pain he was experiencing. This initial
assessment is important to record as it provides a baseline against which to
measure the impact of interventions.
 The description of the wound is somewhat lacking. Although she mentioned
that the wound looked clean and was healing, a more detailed description of
the wound characteristics observed (such as size, color, type of drainage,
presence of granulation tissue, etc.) would provide a better insight into the
wound's current state.
2. Clarity:
NURSING DOCUMENTATION WORKSHOP
September 14-15, 2023
Submitted by: JULIE ANN T. BIOL, RN
 The statement "Wound looks clean and healing" is quite subjective. A more
objective and detailed description of the wound's appearance and any signs
of infection or healing should be included.
 Using more standardized terminology to describe the wound and drainage
might enhance clarity. For instance, instead of "some pus," she could quantify
or describe the characteristics of the pus in more detail.
3. Relevance:
 The documentation could benefit from including relevant details about Mr.
Cruz’s general condition during her shift, like his mental status, ambulatory
ability, etc., especially considering that he lives alone and is planned to return
to his apartment.
 Incorporating information about the patient's decreased sensation in the
affected area, which might be a significant point in assessing the progress or
potential complications of the ulcer.
4. Reflection of Nursing Process:
 The documentation could offer insights into Diane's critical thinking and
clinical judgment process. For instance, her decision to change the dressing
could be substantiated with her assessment findings, like the reduced pain
score.
Overall, while Diane's documentation does cover the basic interventions and responses,
incorporating more detailed and objective information reflecting her complete assessment,
and using a standardized language can improve the quality and effectiveness of her
documentation. This would ensure a comprehensive and accurate reflection of Mr. Cruz's
current state and the care he received.

Number 2:

Patient: Mr. Pedro Cruz

Age: 71 years
Medical History: Type 1 Diabetes
NURSING DOCUMENTATION WORKSHOP
September 14-15, 2023
Submitted by: JULIE ANN T. BIOL, RN
Date: [Specify the date here]
Time: [Specify a time range covering the period from 0800 to post-dressing change]
Nursing Notes:
 0800 hrs: Observed Mr. Cruz with facial grimacing and limping on the right foot
during ambulation to the bathroom. Patient verbalized experiencing constant and
throbbing pain at the site of the ulcer on the right heel, rating the intensity at 6 out of
10.
 0830 hrs: Administered 2 tablets of Tylenol #3 for pain management as per the
physician’s orders.
 0945 hrs: Re-assessed Mr. Cruz's pain level; he reported a significant decrease in
pain intensity, now rating it at 1 out of 10.
 0950 hrs: Proceeded with the dressing change. On removal of the old dressing,
noted the presence of moderate fresh watery and bloody drainage along with a small
amount of green-yellow pus at the wound site. The ulcer measured approximately 3
cm x 4 cm with well-defined borders. The surrounding area exhibited redness. The
majority of the wound bed consisted of granulation tissue, with a smaller portion
covered in yellow slough.
Patient exhibited decreased sensation in the affected foot area; he did not perceive the
coolness of the solution, or the pressure applied during the assessment. Mr. Cruz did not
express any discomfort during the procedure.
Applied new dressing: utilized an adaptive dressing, reinforced with 2 pieces of 4x4 gauze
and secured with a ½ abdominal pad to cover the wound.
Plan:
 Continue to monitor Mr. Cruz’s pain levels and wound healing progress.
 Inform the attending physician of the wound characteristics and patient's response to
pain management.
 Anticipate potential discharge planning with consideration of Mr. Cruz's living
situation.
Nurse's Signature:
Diane [Surname], RN
NURSING DOCUMENTATION WORKSHOP
September 14-15, 2023
Submitted by: JULIE ANN T. BIOL, RN

Scenario 2:

Patient: Mrs. Ada Tan

Age: 89 years
Date: October 12
Time: 0950 hrs
Visiting Nurse: Janie RN
Reason for Visit: Home Transition and Wound Healing Assessment
Initial Observations:
Upon arrival, I observed Mrs. Tan appearing anxious and somewhat unkempt, sitting in her
chair and rocking back and forth. She was clutching her abdomen and moaning, exhibiting
signs of distress. She reported experiencing pain and difficulty in breathing.
Physical Assessment:
 General Appearance: Mrs. Tan appeared somewhat disheveled with a noticeable
fecal odor surrounding her. She was noted to be diaphoretic.
 Mental Status: Mrs. Tan was alert but seemed confused about the time and the last
instance when she took her medications or had a meal. She mentioned that she
spent the night in her rocker.
 Respiratory Status: Mrs. Tan reported difficulty in catching her breath. Upon
assessment, her respirations were noted to be 28 breaths per minute and mildly
labored.
 Cardiovascular Status: Her pulse was measured at 110 beats per minute and
regular. Her blood pressure was noted to be 100/70 mmHg.
NURSING DOCUMENTATION WORKSHOP
September 14-15, 2023
Submitted by: JULIE ANN T. BIOL, RN
 Thermoregulation: Mrs. Tan had a slightly elevated body temperature of 38 degrees
Celsius.
 Pain Assessment: She reported experiencing pain, particularly in her abdomen,
although further details regarding the pain characteristics should be gathered.
Wound Assessment:
Mrs. Tan's surgical site dressing was found in disarray. The site needs a detailed inspection
to assess the current state of the wound and whether there are signs of further infection or
complications.
Plan of Care:
1. Immediate Action:
 Address her pain and difficulty in breathing promptly.
 Assist Mrs. Tan in cleaning herself and changing into fresh clothes to address
the fecal odor.
 Reorganize and secure her surgical site dressing properly.
2. Communication:
 Notify the healthcare provider about Mrs. Tan’s current condition for further
evaluation and guidance on the management plan.
 Contact the caregiver service to ensure regular and possibly increased
support given Mrs. Tan’s current condition.
3. Medication Management:
 Review her medication management strategy with her and possibly her friend
who helps with labeling to prevent any future confusion or missed doses.
 Explore the possibility of setting up a medication reminder system for Mrs.
Tan.
4. Follow-Up Visit:
 Schedule a follow-up visit to reassess Mrs. Tan’s condition and to evaluate
the effectiveness of the interventions initiated.
Notes for Future Consideration:
NURSING DOCUMENTATION WORKSHOP
September 14-15, 2023
Submitted by: JULIE ANN T. BIOL, RN
 Given Mrs. Tan's determination to remain independent, a reassessment of her home
care support and possibly increasing the frequency of caregiver visits should be
considered.
 Collaborate with her neighbor and other support systems to ensure her safety and
well-being.
 Developing a comprehensive care plan that considers Mrs. Tan’s independence
while also ensuring her safety and proper care at home.
Nurse's Signature:
Janie [Surname], RN

This documentation is comprehensive, encapsulating all essential information regarding

Mrs. Tan's current state and planned care interventions. It maintains a factual, clear, and
concise tone and is structured in a way that reflects the systematic approach taken in
assessing and planning Mrs. Tan's care. It also incorporates collaboration with her existing
support system and considers her preference for independence.