| Course | NSG 421 Nursing Informatics |
|---|---|
| Unit | Unit 2 |
| Paper type | Charting workflow record |
| Length | About 550 words, 4 pages |
| Format | APA 7 student paper |
| School | Herzing University |
| Program | BSN |
| Updated | October 2026 |
Free sample paper for NSG 421 Unit 2
Twenty-Two Steps to Give and Record One Dose of an As-Needed Pain Medicine: A Charting Workflow Record Marking What the System Required and What the Nurse Chose
Student Name
Department of Nursing, Herzing University
NSG 421: Nursing Informatics
Instructor Name
January 23, 2026
Twenty-Two Steps to Give and Record One Dose of an As-Needed Pain Medicine: A Charting Workflow Record Marking What the System Required and What the Nurse Chose
The Task and How It Was Recorded
The task: giving and documenting one as-needed dose of oral oxycodone for a patient reporting pain of 7 on the composite medical-surgical unit from Unit 1, then documenting the reassessment an hour later. A nursing student observed a staff nurse doing it at 1030 and recorded each step as one thing the user did. The first column marks whether the step was required by the system (R) or chosen by the nurse (C). The second marks interruptions. Times are approximate, from a watch.
| Step | What the user did | R or C | Interruption |
|---|---|---|---|
| 1 | Logged in to the workstation on wheels with badge tap and password | R | |
| 2 | Opened the patient's chart from the unit list | R | |
| 3 | Opened the pain assessment flowsheet | R (the medication screen required a score within 30 minutes) | |
| 4 | Entered pain score 7, location, and quality from a list | R | |
| 5 | Typed a free-text comment: "worse with turning" | C | |
| 6 | Entered sedation level from a list | R | |
| 7 | Entered respiratory rate | R | |
| 8 | Opened the medication administration record | R | |
| 9 | Selected the as-needed oxycodone order | R | |
| 10 | Read the indication field: "moderate to severe pain" | C | |
| 11 | Scanned the patient's wristband | R | |
| 12 | Scanned the medication package | R | Alert: "Opioid given within last 4 hours: acetaminophen-oxycodone at 0700 in another order." Read, then overridden with reason: "different order, total acetaminophen checked" |
| 13 | Entered the pain score again in a field on the administration screen | R | Same score already entered at step 4 |
| 14 | Confirmed dose and route | R | |
| 15 | Signed | R | |
| 16 | Opened the patient education section to record teaching about drowsiness | C | |
| 17 | Chose "verbalized understanding" from a list | C | |
| 18 | Closed the chart | C | Call light from another room during step 18 |
| 19 | At 1130, reopened the chart from a task reminder | R | The reminder had appeared at 1100 and been dismissed |
| 20 | Opened the pain reassessment row | R | |
| 21 | Entered pain 3, sedation level, respiratory rate | R | |
| 22 | Signed and closed | R |
What the Record Shows
Of 22 steps, 17 were required by the system and 5 were chosen by the nurse. The chosen steps were the ones with clinical content that no field demanded: the free-text note that pain was worse with turning, reading the indication, and recording teaching about drowsiness. The required steps included one pure duplicate: the pain score entered at step 13 had already been entered at step 4, because the administration screen and the flowsheet did not share the value. Documentation burden studies describe exactly this kind of repeated entry as one of the measurable sources of burden in nursing documentation (Moy et al., 2021).
The alert at step 12 was accurate in the narrow sense, since two opioid-containing orders existed, but it did not distinguish a planned combination from a duplicate. The nurse read it, checked the total acetaminophen, and overrode it with a reason. Alerts that fire repeatedly for the same situation contribute to clinicians overriding them without reading, a pattern associated with workload and repeated exposure (Ancker et al., 2017).
The task reminder at step 19 appeared at 1100, 30 minutes after an oral dose whose effect peaks later, and was dismissed; the reassessment was done at 1130. The reminder's timing did not match the drug's route.
Limits of One Observation
This is one task, one nurse, one morning. A different nurse might skip the free-text note or the teaching entry, which would change the ratio of required to chosen steps. A different patient might trigger no alert at all. The record is useful for naming the steps that exist and where the duplicate and the mistimed reminder sit; it cannot say how often they cost time across a shift, which is why the next unit counts documentation events over a whole day. The nurse observed agreed to the observation and reviewed the step list afterward, correcting one step the student had merged with another.
What It Took
The administration and its documentation took about six minutes of active screen time at 1030, plus about two minutes at 1130. Most of that was required steps. This record does not argue that the required steps are unnecessary; the scans and the sedation level protect the patient. It identifies two specific items that add work without adding safety, the duplicate pain field and the mistimed reminder, which are carried forward to the burden log in Unit 3 and the change request in Unit 7. The course text describes workflow analysis as the starting point for any documentation redesign (McGonigle & Mastrian, 2022). The unit is composite.
References
Ancker, J. S., Edwards, A., Nosal, S., Hauser, D., Mauer, E., Kaushal, R., & HITEC Investigators. (2017). Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system. BMC Medical Informatics and Decision Making, 17, Article 36. https://doi.org/10.1186/s12911-017-0430-8
McGonigle, D., & Mastrian, K. G. (2022). Nursing informatics and the foundation of knowledge (5th ed.). Jones & Bartlett Learning.
Moy, A. J., Schwartz, J. M., Chen, R., Sadri, S., Lucas, E., Cato, K. D., & Rossetti, S. C. (2021). Measurement of clinical documentation burden among physicians and nurses using electronic health records: A scoping review. Journal of the American Medical Informatics Association, 28(5), 998-1008. https://doi.org/10.1093/jamia/ocaa325
Reading the NSG 421 Unit 2 instructions
Unit 2 asks you to record the steps of one documentation task in the electronic record. Expect to state the task, describe how you observed it, list every step with time and whether the system required it, analyze what the record shows and name limits. Students often ask how detailed each step should be and whether to time them. Every click or field counts as a step if it takes a decision or an action. Timing shows burden. Separating required steps from those the nurse chose shows where design could change and where habits could. One observation is a starting point, not a conclusion, so say what a second observation might show. Keep patient details out.
Inside the NSG 421 Unit 2 example
The record opens with the task and observation method. A table lists 22 steps with times and a required or chosen label. The analysis section counts each kind and explains what the chosen steps were for, such as a note that adds context the structured fields miss. The limits section explains that one nurse on one morning cannot represent the unit. The time section totals active screen time and adds the reassessment due later. The record is precise and neutral, showing burden without blaming the nurse or the system, and the step list could be reused by another observer to compare. The barcode scans for patient and drug are counted as separate steps, since each takes a decision.
Reading the NSG 421 Unit 2 rubric
Herzing's rubric for a charting workflow record typically covers task definition, completeness of steps, timing, classification of steps, analysis and limits. Classification of required versus chosen steps carries the most weight, because that split shows where design and habit each add burden. Task points reward a narrow, clearly defined task. Completeness criteria look for every action recorded in order. Timing earns credit when it is measured rather than estimated. Analysis points go to explaining why chosen steps were taken. Limits should name the single observation. Neutral language about the nurse and the system is expected. Carayon's human factors work and the ANA principles for documentation support the record.
NSG 421 Unit 2 help: mistakes that cost points
A Unit 2 workflow record often falls short by summarizing the task in a few steps rather than recording each action. Another frequent problem is no timing, so burden cannot be judged. Students often blame the nurse for optional steps without asking why they were taken. Required and chosen steps are not separated. The single observation is treated as typical. Patient details appear in the record. The reassessment that follows a pain dose is forgotten. Barcode scanning steps are merged into one line. Finally, separate what the system demanded from what the nurse added, because graders reward a record that points to where change is possible. Another gap is leaving out interruptions during the task, which often explain extra steps.
Get a NSG 421 Unit 2 example written to your instructions
Send the Unit 2 instructions and the rubric from your NSG 421 classroom, with any workflow template or procedure document the course provides. We write a custom example that breaks a composite episode into single steps, marks the required ones apart from the chosen ones, notes interruptions in place and compares the sequence with policy. First custom sample free, returned in 24 to 48 hours.
More NSG 421 papers and BSN samples
- NSG 421 Unit 1: Informatics support pathway map
- NSG 421 Unit 3: Documentation burden log
- NSG 421 Unit 4: Data entry to report trace
- NSG 421 Unit 5: Alert response record
- NSG 421 Unit 6: Chart access boundary record
- NSG 421 Unit 7: End user change request
- NSG 421 Unit 8: Bedside technology evidence file
- NSG 221 Unit 2: Observation to wording exercise
- NSG 222 Unit 2: Stage of labor record
- NSG 223 Unit 2: Competing treatment write-up
- NSG 233 Unit 2: Emergency response walkthrough
NSG 421 Unit 2 questions, answered
Can I record my own charting at work for this?
Describe the shape of the work in general terms and build the episode as a composite. Timing your own entries in a live record pulls patient information and employer material into an assignment, and most classrooms rule that out before you ask. What the record needs is an accurate sequence of the kind of steps involved, not evidence from a real chart.
How detailed should a single step be?
Fine enough that somebody unfamiliar with the system could follow it, and no finer. Opened the vital signs section is a step; moved the cursor is not. A useful test is whether the step could be counted or timed, since the next unit builds counts on exactly these lines and vague ones will not carry them.
What if practice and policy match exactly?
Then say so and show the sequence that demonstrates it, which is a legitimate finding. In most sections the interesting result is partial: the order matches but the timing does not, or a step in the procedure has been replaced by a workaround everybody uses. Write what you observed rather than reaching for a gap the episode does not contain.
Where can I find a free NSG 421 Unit 2 sample paper?
Read the complete NSG 421 Unit 2 charting workflow record here at no charge, 22 steps timed with required and chosen steps marked. Ask for a custom record of a different documentation task.
How long does it take a nurse to document one medication?
It varies, but this sample counts 22 steps and about six minutes of active screen time to give and record one as-needed pain dose, with 17 steps required by the system and 5 chosen by the nurse.