Analysis

Assignment #2: Charting/Case Notes Analysis Essay
Due: Sunday, February 28 to dropbox by 11:59 pm
Length: approx. 750-1050 words (3 pages double-spaced)
Value: 15%
Below you will find three short notes that might be found in a client
chart/record:
 Patient arrived emerg cut forehead. Patient clearly drunk,
possib. othr drgs. Agitated, non- compliant. Fell while
drunk. At one pt. threatened staff, seemed like might be
violent. Psych/SW consult.
 Client had a good day today, lungs snd good. Asleep 8-12,
woke vitals at 10. Unsteady when wash. Rec. walk. to
assist.
 Patient started to cough and breathe rapidly, yelling that
she is about to faint and that she can’t breathe anymore.
Considering that someone about to lose consciousness does
not have the strength to yell, it must be concluded that the
patient is faking her symptoms.
Each of these notes is problematic in a variety of ways. Based on our
class discussions, analyze these notes in essay form. Your essay should
1) outline, in your introduction, general principles regarding the use
of clear, objective language in patient notes. You may wish to use
Chapters 1, 2, and 5 in our textbook and/or other sources such as
Jensen’s Nursing Health Assessment or Fundamentals of
Nursing. You may also wish to use the quotations about the
importance of documentation that we discussed at the beginning
of the course. If you use materials from these texts, please cite
them carefully using APA format!
2) analyze each of the above notes in terms of these principles. Be
sure to connect your analysis of each note clearly to the
principles discussed in your introduction.
3) reflect on how the notes can be improved in light of these
principles
4) rewrite the notes in light of your analysis and reflections in 1-3.
You will have to use your imagination here.
In terms of structure, I suggest that after the introduction, you devote a
paragraph to each note. Each of these paragraphs should address steps
2-4. The rewrite can be set off like a long quotation, but with no
citation.
Be selective: you will not have enough space to analyze every word of
each note fully, so pick a few representative examples for your
analysis.
When you rewrite the note, however, you should correct everything
that you see that you think could be improved.
Then, write your conclusion, summarizing the main errors and how
they were corrected.
Evaluation:
Your assignment will be marked for:
-adherence to the instructions provided above
– clear summary of principles of good writing
-sound analysis of the notes
-clear, concise, and specific rewrites
-proper use of essay, paragraph, and sentence structure
-proper mechanics (grammar, spelling, capitalization, etc.)
-proper use of APA documentation style
-This assignment will NOT judge the correctness of health-related
content or of a specific charting (e.g. SOAPS) format.