ACP Flip Book

All nursing exams are modeled after the NCLEX exam given by each State Board of Nursing. I have created
my test questions in that same format. Since this is my second semester to teach and I haven’t done a
classroom, I’ve modified existing test questions to fit my lesson plan.

Lesson: Constructing a Nursing Narrative

Course Student Learning Outcome: The student will be able to demonstrate legal and ethical behavior, safe
practices, interpersonal and teamwork skills and appropriate written and verbal communication skills using the
terminology of the occupation and business/industry.

Learning Objectives: By the end of this lesson, students should be able to:

1. compile assessment data for documentation in the clinical setting

2. demonstrate correct computer usage and documentation in the clinical setting

1. T/F The nurse has made a documentation error. Using white out to correct the mistake is the
correct method of change. Blooms Knowledge. Knowing correct from incorrect.

Answer: False. Draw line through documentation error and initial.

2. Which of the following items of subjective client data would be documented in the medical record

by the nurse? Blooms Comprehension. Classifying objective data from subjective data

A. Client's face is pale

B. Cervical lymph nodes are palpable

C. Nursing assistant reports client refused lunch

D. Client feels nauseated

Answer: D. Client feels nauseated. Subjective data includes the client's sensations, feelings, and
perception of health status. Subjective data comes from the patient or patient’s family. Options A, B and

C represent objective data that can be detected by the nurse or measured against an accepted norm.

3. The nurse realizes that effective nursing documentation encourages: (Select all that apply.)

Blooms Analysis. Analyze data to support generalization

A. Safe nursing practice
B. Continuity of client care
C. Positive client outcomes
D. Efficient time management
E. Cost-conscious nursing care
F. Effective nurse-client relationships

Answer: A. Safe nursing practice, B. Continuity of client care, D. Efficient time management
Options C, E and F are part of the nursing process but not part of effective nursing documentation.

4. The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a
progress note for the LTC staff to reflect which of the client's outcome goals that met and those
that were not met. To do this effectively, the nurse should: Blooms Evaluation. Interpret data and
draw conclusions
A. Formulate post-discharge nursing diagnoses
B. Draw conclusion about resolution of current client problems
C. Assess the client for baseline data to be used at the LTC facility
D. Plan the care that is needed in the LTC facility

Answer: B. Draw conclusion about resolution of current client problems. Evaluation is done to determine
the client's condition upon discharge. This evaluation is best reflected in option B because it focuses on
which goals were achieved and which were not. Ongoing evaluation is done while or immediately after
implementing a nursing intervention. Intermittent evaluation is performed at specified intervals, such as
twice a week. Items related to care post-discharge (options B, C and D) should be done on admission to the
LTC facility.

Name: __________________________________________ Date: _______________
Quiz name: Nurse Narrative Charting
Standard: HI.9

The nurse has made a documentation error. Using white out to correct the mistake is the correct
1. method of change.

A True

B False

Which of the following items of subjective client data would be documented in the medical record by
2. the nurse?

A Client's face is pale
B Cervical lymph nodes are palpable
C Nursing assistant reports client refused lunch
D Client feels nauseated

The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress
note for the LTC staff to reflect which of the client's outcome goals that met and those that were not
3. met. To do this effectively, the nurse should

A Formulate post-discharge nursing diagnoses

B Draw conclusion about resolution of current client problems

C Assess the client for baseline data to be used at the LTC facility

D Plan the care that is needed in the LTC facility

Which is the most appropriate notation for a use to use according to the guidelines that should be
4. followed when documenting client care?

A 1230—Client's vital signs taken.
B 0700—Client drank adequate amount of fluids.
C 0900—Demerol given for lower abdominal pain.
D 0830—Increased IV fluid rate to 100 mL/hr according to protocol.

Which of the following nursing notations shows the best understanding regarding the need to
5. document only objective client assessment data?

A "Client was angry because breakfast was not to her liking."
B "Client is depressed; was observed crying while alone in room."

C "Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her
fists."

D "Client was verbally abusive to staff when approached concerning client's continued attempts to
smoke in the bathroom."

Page 1 of 1

Nurse Narrative Grading Rubric

Below Average Average Above Average Exceptional
10 pts 15 pts 18 pts 20 pts

Documentation is Documentation does Documentation meets Documentation meets Documentation is clear
clear and well
organized not meet expectations criteria but criteria with occasional and well organized.

as evidenced by the unorganized. redundant or distracting Appropriate medical

following: lay Documentation information, clear but terminology is used.

terminology, illogical occasionally strays slightly unorganized Redundant words,

sequencing, missing from standard format and occasionally strays phrases, and other

essential elements, and logical sequence from standard format distracting information

more than 2 spelling or for H2T documentation for H2T documentation are omitted. Format

grammatical errors. No but the reader is able to Reader is able to follows a standard

follow up notes are determine findings with determine findings with narrative for H2T with

present. Plagiarism difficulty. Follow up minimal difficulty. complete follow up

noted from other health notes are incomplete Follow up notes are notes.

care provider notes. present.

Subjective assessment Subjective assessment Subjective assessment Subjective assessment Subjective assessment

is fully explicated is missing more than 2 is missing 2 elements is missing 1 element is fully explicated and

critical elements needed for adequate needed for adequate targeted toward the

needed for adequate evaluation of the evaluation of the reason for presentation
evaluation of the with no irrelevant
patient's problem. patient's problem. patient's problem. No information or missing
Irrelevant information assessment elements.
predominates Includes some irrelevant information
subjective assessment
irrelevant information. is present.

Objective assessment Objective assessment is Objective assessment is Objective assessment is Objective assessment is

is fully explicated not developed and/or missing 2 elements missing 1 element fully explicated and

the assessment is needed for adequate needed for adequate targeted toward

inappropriate for the evaluation of a patient's evaluation of the evaluation of the
patient’s problem with
patient's age, gender, problem. patient's problem.

and/or inappropriate for no missing assessment

the presenting problem. elements.

Safety and Comfort Documentation lacks Documentation meets Documentation meets Documentation is clear

three or more of the but unorganized. criteria but with and well organized.

following: safety Documentation occasional redundant Appropriate medical

precautions in place, occasionally strays information and terminology is used.

lay terminology, and/or from standard format occasionally strays Redundant words,

more than 2 spelling or of safety and comfort from standard format phrases, and other

grammatical errors. documentation. Reader of safety and comfort distracting information

Plagiarism noted from is able to determine documentation. Reader are omitted. Safety and

other health care findings with difficulty. is able to determine comfort format follows

provider notes. findings with minimal a standard and logical

difficulty. flow.

Formatting Documentation does Documentation meets Documentation meets Documentation is clear

not meet expectations expectations but criteria but exhibits one and well organized.

as evidenced by any of exhibits one or more of of the following: no Appropriate medical

the following: no nurse the following: no nurse nurse signature, no terminology is used

signature, no time or signature, no time or time or date, no line and narrative is mistake

date, no line drawn date, no line drawn drawn between end of free.

between end of between end of sentence and nurse

sentence and nurse sentence and nurse signature, illegible

signature, illegible signature, illegible handwriting, multiple

handwriting, multiple handwriting, multiple spelling mistakes

spelling mistakes spelling mistakes



Name: Deania L. Hoffpauir
Discipline: Nursing ADN
Date: April 22, 2016

 B-Bridge in

 Student Prep Strategy

 O-Objectives

 Motivation

 P-Pre-Assessment

 P-Participatory

 CAT-concept map
 Lesson Plan
 Technology-Socrative/Poll Everywhere

 P-Post Assessment

 Assignment assessment

 S-Summary

 Summary Survey

 Reflection



Class Prep Assignment

(intro) With the advent of computers, you’d think
paper charting would be a thing of the past but not
so! You will experience times when you are not able
to chart on the computer and must revert back to
paper charting.

This class will show you how to create a nurse
narrative on paper.

Reading + questions

Read: Chapter 1 & 2 in “Nursing Documentation
Quick and Easy.

Answer and bring to class:
1. How would you ensure that your narrative is

in chronological order? (Blooms Application)
2. How would you prevent cluster or double

charting? (Blooms Synthesis)
3. Should everyone’s charting look the same?

Why or why not? (Blooms Evaluation)
4. Discuss what to include or not include in our

narrative. (Blooms Analysis)

Malcolm Knowles Adult Learning Theo

 Adults are most interested in learning s
and impact to their job or personal life.

 Explain why this lesson is important, its rel

 Adults need to be involved in the plann

 Start learning cycle with the reading assign

 Experience (including mistakes) provid

 Provide pre-assessment with 4 questions

 Adult learning is problem-centered rath

 Provide examples, learning activities and cl

ory Principles
subjects that have immediate relevance

levance

ning and evaluation of their instruction.

nment

des the basis for the learning activities.

her than content-oriented.

larification of concepts

Outcomes and Objectives

Course Outcome: The student will be able to
demonstrate legal and ethical behavior, safe
practices, interpersonal and teamwork skills
and appropriate written and verbal
communication skills using the terminology of
the occupation and business/industry.

Learning Objectives: By the end of this lesson,
students should be able to:
1. compile assessment data for documentation
in the clinical setting
2. demonstrate correct computer usage and
documentation in the clinical setting

Criteria for Success

Class questions, quizzes and PrepU exercises
carry same weight as exams.

Must come to class prepared to get full grade
credit. Failure to complete one portion results
in a zero

Class time will be spent in learning activities to
augment reading and to clarify concepts.

Ways to motivate students:
 Give an example (or 2) on how I worked through the

stresses of nursing school.
 Have students reflect on a past experience and what they

used to get through a tough time
 Foster study group participation to teach and encourage

each other
 Examine their goals-what do they want to do with the

time they have left in nursing school and what are their
goals after nursing school
 Remind them that the reward is that RN degree and
their choice of dream jobs

 Be enthusiastic! Get them to love nursing as much as I
do

 Provide case studies as examples of ideas put into real
life situations

 Praise them when they identify an important concept
and remind them that a mishap is a “learning
opportunity”. It’s only a mistake the second time.

 Explain that hundreds of nursing students pass nursing
school. If they can, YOU can.

 Lastly, reiterate that all nurses were students once. They
had to learn to crawl before they could learn to walk.
Great nursing is a work of art and takes time.

 Empower them-“you’re halfway there, almost done!”

My needs
 What do they already know?

 Open ended questions

 Consistent with objectives

 Consistent with post assessment

Pre assessment questions
 What items do you include in your

nursing narrative?

 How many times a day should you
chart?

 What do you do if you make a
mistake in your charting?

The current CAT trend in nursing is the
concept map. This allows faculty to assess
the student’s ability to synthesize the
course materials with the student’s
knowledge and skills. It can also offer
insight into how a student views and
organizes that knowledge.
Students would fill in what they think
should be included in the initial nurse
narrative. I would then present the power
point and nurse narrative examples.
Students would use then make necessary
corrections to their concept map. This way,
I can assess prior knowledge plus new
knowledge as well as how students use their
critical thinking skills.



COURSE: RNSG 2361 Traditional and Simulation, Level III
Lesson Title: Constructing the Nursing Narrative

Bridge: (intro) With the advent of computers, you’d think paper charting would
you are not able to chart on the computer and must revert back to paper char
paper.

Read Chapter 1 & 2 in Nursing Documentation: Quick and Easy. Download th
create a 7AM “head to toe” assessment on a patient using the blank narrative a
and not include in your narrative.

Estimated Time: 30 min. non classroom time

Course Student Learning Outcome: The student will be able to demonstrate legal and
appropriate written and verbal communication skills using the terminology of the oc

Learning Objectives (these should be the ones you wrote in Module 1): By the end of
1. compile assessment data for documentation in the clinical setting (Blooms Level: S
2. demonstrate correct computer usage and documentation in the clinical setting (Bl

Pre-Assessment: How will you assess learning prior knowledge of the topic?
1. Create 7am head to toe assessment using sample data and blank form. Downloa
2. In class, complete concept map prior to lecture (handout).

Participatory Learning:

Time Instructor Activities Learner Activ

10 min PPT presentation Explains imp
narrative. Pa
15 min Watch patient YouTube video throughout p
Provide Yout
Using video,
to Toe narrat

d be a thing of the past but not so. You will experience times when
rting. This class will show you how to create a nurse narrative on

hese three documents (see attached). Using the examples provided,
above and bring it to class. Be prepared to discuss what to include

d ethical behavior, safe practices, interpersonal and teamwork skills and
ccupation and business/industry.
this lesson, students should be able to:
Synthesize)
looms Level: application )

ad and bring to class

vities Lesson Materials

portance of good nurse documentation and Handout of PPT slides
ause for clarification and questions Blank narrative handout
presentation
tube video at end of slide presentation.
allow students to practice creating a Head
tive assessment

10 min CAT concept map Have students com
15 min Discussion of Examples/ask questions second time using
Compare differenc

Review concept map
with the following q

Question 1: How wo
chronological order?
Question 2: How wo
charting? (Blooms sy
Question 3: Should e
or why not? (Blooms
Question 4: What sh
narrative? (Blooms a

20 min Create groups of 3 students each and create a nurse Students strategize o
narrative each other

mplete original concept map a Concept map
g newly acquired information.
ce in both.

p and H2T assessments. Clarify material
questions:

ould you ensure that your narrative is in
? (Blooms application)
ould you prevent cluster or double
ynthesis)
everyone’s charting look the same? Why
s evaluation)
hould you include or not include in your
analysis)

on writing nurse narrative and evaluate Handout of sample patient
info
Blank narrative handout

Post Assessment:

1. Nurse narrative grading rubric (see attached)
2. New Technology: Socrative Nursing Documentation quiz

Estimated time: 10 min

Summary: how will you close the lesson?

1. Verbal content review
2. Recognition to top performers (hopefully everyone)
3. Group roundtable on practical application and potential future use

Estimated Time: 10 min

Attachments:

(1) Introduction
(2) nurse narrative examples
(3) Blank Nurse narrative form
(4) Sample Patient information
(5) Nurse narrative grading rubric



1. T/F The nurse has made a documentation error. Using white out to correct the mistake is the correct method of
Answer: False. Draw line through documentation error and initial.

2.Which of the following items of subjective client data would be documented in the medical record by the nurse?
A. Client's face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feels nauseated

Answer: D. Client feels nauseated. Subjective data includes the client's sensations, feelings, and perce
data that can be detected by the nurse or measured against an accepted norm.

3 The nurse realizes that effective nursing documentation encourages: (Select all that apply.) Blooms Analysis. Ana
A. Safe nursing practice
B. Continuity of client care
C. Positive client outcomes
D. Efficient time management
E. Cost-conscious nursing care
F. Effective nurse-client relationships

Answer: A. Safe nursing practice, B. Continuity of client care, D. Efficient time management. Options

4.The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note for the L
effectively, the nurse should: Blooms Evaluation. Interpret data and draw conclusions
A. Formulate post-discharge nursing diagnoses
B. Draw conclusion about resolution of current client problems
C. Assess the client for baseline data to be used at the LTC facility
D. Plan the care that is needed in the LTC facility

Answer: B. Draw conclusion about resolution of current client problems. Evaluation is done to determine the client's cond
which were not. Ongoing evaluation is done while or immediately after implementing a nursing intervention. Intermittent
and D) should be done on admission to the LTC facility.

ASLO OFFERED ON SOCRATIVE socrativeNurseNarrativeQuiz.xlsx