For this charting assignment, you will be using charting by exception (CBE). You will utilize the information you gathered during the Lung and Thorax lab class from a peer. Please do not include any identifying information on your charting forms.
You will need to complete the following sections on the NISS CBE “Systems Assessments” form. Just use the Day section. While there is a small section in the form to chart narratively “Other System Component,” please use a narrative form (also attached here) in the assignment. You will include the full lungs/thorax focus assessment (narrative) on the Notes document.
Systems Assessments – Day.pdf Download Systems Assessments – Day.pdf
Notes.pdf Download Notes.pdf
1) CNS – “tick” the normal assessments, and also any abnormality. If any abnormality, please describe more detail narratively.
2) Resp – “tick” any normal findings, and also any abnormality. If any abnormality, please describe more detail narratively. This section on the form is limited, so you will also need to include details from your assessment, even normal ones, in the narrative charting. Begin this section of your narrative entry with Subjective information your peer told you. Then move the Objective findings. See the rubric for the detail to include. This represents the main focus of this assessment.
3) Integumentary – “tick” the normal assessments, and also any abnormality. If any abnormality, please describe more detail narratively.
4) Mobility/MS – “tick” the normal assessments, and also any abnormality. If any abnormality, please describe more detail narratively.
5) Psychosocial – “tick” the normal assessments, and also any abnormality. If any abnormality, please describe more detail narratively.
You can leave the rest of the form blank, but do sign, date and time the entry. You’ll almost certainly need to “tick” the “See Nursing Notes” box.
5) Narrative – narrative chart a full lungs/thorax assessment. Use the lungs/thorax checklist (practiced in class) as a guide. Please see rubric (attached below) for additional details.
6) Finally, include at least one specific health promotion teaching point having to do with Lungs and evidence of the peer’s understanding (called, “response” usually). This is of course, in the narrative Notes since no teaching is mentioned on the CBE form.
See Chapter 19 in your textbook for some example phrases to include narratively (Documentation section of chapter).
Please hand write the charting and upload the narrative charting form(s) and the Systems Assessment form as a digital file here in Canvas either as a jpg or pdf scan. Please no HEIC files. Leave the Pt. Identity section blank for now to maintain confidentiality.
Rubric
Lungs and Thorax (1)
| Criteria | Ratings | Pts | ||||||
|---|---|---|---|---|---|---|---|---|
| This criterion is linked to a Learning OutcomeEntry information Date, time, component and discipline
|
|
2 pts | ||||||
| This criterion is linked to a Learning OutcomeCBE CNSPlus any abnormal descriptions in narrative notes.
|
|
2 pts | ||||||
| This criterion is linked to a Learning OutcomeCBE Resp
|
|
2 pts | ||||||
| This criterion is linked to a Learning OutcomeNarrative Resp – Subjective informationInclude at least two pieces of subjective assessment data.
|
|
2 pts | ||||||
| This criterion is linked to a Learning OutcomeNarrative Resp – Inspection details
|
|
2 pts | ||||||
| This criterion is linked to a Learning OutcomeNarrative Resp – Palpation details
|
|
2 pts | ||||||
| This criterion is linked to a Learning OutcomeNarrative Resp – Percussion details
|
|
2 pts | ||||||
| This criterion is linked to a Learning OutcomeNarrative Resp – Auscultation details
|
|
2 pts | ||||||
| This criterion is linked to a Learning OutcomeNarrative Resp – SpO2, Resp rate, depth, quality, rhythm
|
|
5 pts | ||||||
| This criterion is linked to a Learning OutcomeCBE IntegumentaryPlus any abnormal descriptions in narrative notes.
|
|
2 pts | ||||||
| This criterion is linked to a Learning OutcomeCBE Mobility/MusculoskeletalPlus any abnormal descriptions in narrative notes.
|
|
2 pts | ||||||
| This criterion is linked to a Learning OutcomeCBE PsychosocialPlus any abnormal descriptions in narrative notes.
|
|
2 pts | ||||||
| This criterion is linked to a Learning OutcomeHealth Promotion Teaching and responseAt least one specific (lungs/thorax) teaching point including client response (evidence of understanding)
|
|
4 pts | ||||||
| This criterion is linked to a Learning OutcomeMechanics/charting principles
|
|
1 pts |