Assignment Paper

Assessment Task 3
Assessment name: Health Assessment paper. Communicating Findings : Written Report and Reflection

Learning Outcomes measured:
1. Conduct a health assessment using a range of data collection methods and accurately document these findings.
2. Recognise normal health parameters in order to identify actual and potential health problems
3. Begin to use a structured clinical reasoning process and apply knowledge of health assessment to the provision of evidence based, person-centred care, including an initial plan of action
4. Apply professional communication skills in line with culturally safe practice to undertake effective health assessments.
5. Apply critical thinking and reflection skills to analyse health assessment practice.
Length: 1000 words
Estimated Time to complete task: 12 – 15 hours

Weighting: 40%
Individual/Group: Individual
Authentic Assessment: Yes
Formative/Summative:
Summative
How will I be assessed: 7 point grading scale using a rubric

Due date: Due Friday 29th May 2020
Submit via Turnitin in your NSD103 Blackboard site
Your paper must be completed and successfully uploaded before 11.59 pm.
More information about Turnitin is available on the FAQs about Turnitin page.

Task description: Health assessment underpins all health care professionals (HCP) care decisions. A variety of assessment techniques and skills are used to gather information. These skills include observation, interview, and clinical skills to measure vital signs and focused assessments.

This assessment task requires you to watch a 15 minute video of an RN assessing a patient (use the link below), document the findings, analyse the data, write a report of your findings and reflect on your assessment techniques.
QUT (2017) Health Assessment – Adult
https://mediawarehouse.qut.edu.au/QMW/player/?dID=42935&dDocName=QMW_035009

Presentation requirements:

Complete, sign and attach the QUT Assignment Cover Sheet
The written report
• Use the data collected by the RN in the video
• Use the SBAR framework as headings to structure your written report
• Use professional language and write in the third person
The Reflection
• Use the STARL framework as headings to structure your reflection on the assessment technique
• Use professional language and write in first person as necessary
Attach as an appendix to your written report
• Your completed observation charts or forms
General Requirements
• Do not include an introduction or a conclusion
• Do not use borders
• Do not use bullet points or numbering
• Use academic writing
• Use Arial, Calibri or Roman New Times font, size 11 or 12, 1.5 to 2 spacing.
• Use literature to support your discussion in both sections
• Use QUT APA7 referencing for citing academic literature in text and reference list
Including page numbers
• Minimum 7 academic quality sources Submit documents in electronic format as a single word document via Turnitin.
What you need to do:
Watch the health assessment video, analyse and document the findings, write a handover report and reflect critically on the assessment techniques:

A) Record data on the appropriate chart or forms. Access these from the Assessment 3 resources on your Bb site
B) Write a handover report: Findings collected from the video are to be analysed and reported in a written handover using the SBAR framework as a guide (approximately 750 words).
C) Reflect critically on the nurses assessment techniques and skills used during the health assessment using the STARL framework as a guide (approximately 250 words).
Template
to structure your
paper

A) The written handover report
Use the SBAR framework as headings to communicate your findings and your plan of care to other HCPs . This should reflect the health assessment of the person in the video (approximately 700 words)
Define and reference SBAR
Situation. (approximately 100 words)
This initial step of the SBAR should include the following;
• Accurately identify the RN and the person’s name, age and gender
• Identify the person’s presenting complaint (what has led the person to seek health care) and the current clinical context of the situation (what condition the person is currently in)
Background. ( approximately 150 words)
Provide a clear description of the significant background information and relevant history in the person’s health/ health care related to:
• The presenting complaint
• Previous medical, surgical and/ or family history.
• Social and emotional situations or contexts
Assessment findings. ( approximately 350 words)
Describe the assessment process undertaken to gather the necessary data:
• For example, primary survey, general survey, patient interview, a focused or comprehensive assessment and vital signs.
• Use literature to briefly explain how / why all of these assessment strategies are important.
• Analyse and then report your findings:
o Compare the data collected from the cased study with normal parameters in your text book ( Estes et al 2016 or Calleja et al 2020)
o Identify any abnormal data
o Make connections between data from the initial assessment and focused assessments and the patient situation or presenting complaint
o Identify the person’s problems
o Use additional literature to justify your clinical decisions /problems
Recommendation. ( approximately 100 words)
Communicate your recommendations to other HCPs including the following in an initial plan of care:
• Identify (from the abnormal data identified in the assessment findings) and justify one priority health problem experienced by the person and justify one health care goal for that problem.
• Do not explain interventions that fix the problem
• What recommendations for further assessment were required by the nurse to fully understand the health status of the patient. ( Is there any missing data)?
• Use additional literature to justify your choice of priority health problem, your recommended goals of care (explain why it is a priority) and the need for further assessment.
B) Reflection on your Assessment Technique
• Use the STARL framework to reflect critically on the assessment techniques used
by the RN (both interview skills and clinical skills/ techniques). Use the template below to assist you in writing your responses.

Reflection using STARL (approximately 300 words)
Situation.
• Describe the situation and environment where the RN conducted the health
assessment and interview.
Task.
• Briefly describe the tasks the RN was required to do (identifying at least 3 different assessment frameworks or focused assessments).
Action.
• Describe what the RN did to perform each assessment framework or focused assessments.
• What communication skills were used by the RN in each stage of the interview (the joining, working and termination stages)?
• How did the RN go about assessing vital signs?
Results/Reflection.
• What was the result of the task? How well did you understand the person’s health status and problems based on the RNs assessment findings?
• Reflect on the interview process (joining, working, terminating stages)
o How well did the RN interview the person?
o What information was missing?
• Reflect on the RNs clinical skills techniques (vital sign measurement).
o What focused Assessment were performed and summarise the findings?
o Were there any further data that would make these more comprehensive?
o What vital signs were assessed and were there any abnormalities?
o What didn’t go well with your vital sign assessment?