Summary Shadow Health - Communication and Documentation

NURC 208 LPN to BSN Transition
Shadow Health Communication and Documentation

 Care Plan Tutorial: A nursing care plan is a formal process that identifies existing needs and
recognizes potential needs or risks. The process of developing a care plan begins when the client is
admitted and is continuously evaluated and updated during their time under nursing care.
 Documentation - Best Practices: Making sure all documentation is complete, correct, and timely is an
important responsibility of being a practicing healthcare provider. This tutorial explores best practices
for documenting patient data at Shadow Health patient care locations.
 Documentation - History of Present Illness (HPI): This tutorial explores best practices for
documenting the HPI.
 Documentation - Past Medical History: This tutorial explores best practices for documenting a
patient's past medical history.
 Documentation - Social History and Review of Systems: This tutorial explores best practices for
documenting a patient's social history and review of systems.
 Documentation - Objective Data: This tutorial explores best practices for documenting a patient's
objective data.
 SBAR Tutorial: Many clinical sites implement a communication protocol called an SBAR handoff to
help us ensure we communicate all the critical pieces of information to other care providers. Using the
SBAR technique, the provider gives the situation, background, assessment, and their recommendation.