1
vSim Health Assessment Case 9: Edith Jacobson
Documentation Assignments
1. Document your findings related to the focused assessment regarding Mrs.
Jacobson’s neurologic status. Include her responses to your assessment.
• When I checked her pupils, they were round and reactive to light.
• During her mini-cog assessment, she did great. She was able to repeat the words I told
her to remember and drew the correct time on the clock.
• While checking her GCS assessment, she got a 15, which is normal.
2. Document your findings related to the Mini-Cog and falls assessments of Mrs.
Jacobson. Include her responses to your assessments.
• She was aware of her risks for falling. She showed me that she understood by telling me that
she will use the call light when trying to go to the bathroom or to get out of the bed at all. She
was able to recall the 3 words I asked her to remember and was able to draw the accurate time
on the clock.
3. Referring to your feedback log, document all nursing care provided and Mrs.
Jacobson’s response to this care.
• I assessed her pain level (which was a 2 in her left leg that worsens with movement); I
educated her on fall risks and asking for help to get up, pain management and plan of care;
She had previous knowledge on each of the things I educated her on.
• I performed a focused neuro assessment (mini-cog & GCS), and she was able to recall the words I
asked her to remember and drew the correct time on the clock. She got a 15 on her GCS, which
is normal.
4. Document all patient teaching regarding assessments and safety issues provided to Mrs.
Jacobson, and her response to the teaching.
• I educated her on use of her call bell for assistance to get out of bed for any reason, and she
showed previous knowledge on that. I told her I had to perform some assessments on her,
which initially she seemed anxious about, but after I explained what I was doing, it seemed to
ease her
anxiety.
5. Document your handoff report in the SBAR format to communicate Mrs. Jacobson’s
future needs.
• S: This is Edith Jackson, 85-year-old female who was admitted after having a dizzy
spell, resulting in a fall where she fractured her hip and hit her head. An x-ray has been
taken and shows a left hip fracture. She also had a CT of her head, and those results
, 1
showed
vSim Health Assessment Case 9: Edith Jacobson
Documentation Assignments
1. Document your findings related to the focused assessment regarding Mrs.
Jacobson’s neurologic status. Include her responses to your assessment.
• When I checked her pupils, they were round and reactive to light.
• During her mini-cog assessment, she did great. She was able to repeat the words I told
her to remember and drew the correct time on the clock.
• While checking her GCS assessment, she got a 15, which is normal.
2. Document your findings related to the Mini-Cog and falls assessments of Mrs.
Jacobson. Include her responses to your assessments.
• She was aware of her risks for falling. She showed me that she understood by telling me that
she will use the call light when trying to go to the bathroom or to get out of the bed at all. She
was able to recall the 3 words I asked her to remember and was able to draw the accurate time
on the clock.
3. Referring to your feedback log, document all nursing care provided and Mrs.
Jacobson’s response to this care.
• I assessed her pain level (which was a 2 in her left leg that worsens with movement); I
educated her on fall risks and asking for help to get up, pain management and plan of care;
She had previous knowledge on each of the things I educated her on.
• I performed a focused neuro assessment (mini-cog & GCS), and she was able to recall the words I
asked her to remember and drew the correct time on the clock. She got a 15 on her GCS, which
is normal.
4. Document all patient teaching regarding assessments and safety issues provided to Mrs.
Jacobson, and her response to the teaching.
• I educated her on use of her call bell for assistance to get out of bed for any reason, and she
showed previous knowledge on that. I told her I had to perform some assessments on her,
which initially she seemed anxious about, but after I explained what I was doing, it seemed to
ease her
anxiety.
5. Document your handoff report in the SBAR format to communicate Mrs. Jacobson’s
future needs.
• S: This is Edith Jackson, 85-year-old female who was admitted after having a dizzy
spell, resulting in a fall where she fractured her hip and hit her head. An x-ray has been
taken and shows a left hip fracture. She also had a CT of her head, and those results
, 1
showed
