Documenting Respiratory, Cardiovascular and Neurological Systems
September 19, 2016

Documenting Respiratory, Cardiovascular and Neurological Systems

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function. Use this table to evaluate your general

More info
Documenting GU, Skin and Reproductive Systems
September 12, 2016

Documenting GU, Skin and Reproductive Systems

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function. Use this table to evaluate your general

More info
Documenting EENT, GI, and Musculoskeletal Systems
September 5, 2016

Documenting EENT, GI, and Musculoskeletal Systems

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function.  Use this table to evaluate your general

More info
Documenting Communication and Cognitive Function
August 29, 2016

Documenting Communication and Cognitive Function

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function.  Use this table to evaluate your general

More info
Documenting Appearance and Mobility
August 22, 2016

Documenting Appearance and Mobility

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function. Use this table to evaluate your general

More info
August 15, 2016

Subjective Data and Patient Assessment

Objective data includes measurable and observable criteria that are specific to a clinical problem. Objective indicators are factual that can be observed. These types of data are obtained through ...

More info
August 8, 2016

Objective Data and Patient Assessment

Objective data includes measurable and observable criteria that are specific to a clinical problem. Objective indicators are factual that can be observed. These types of data are obtained through ...

More info
Document What You Do Checklist
August 1, 2016

Document What You Do Checklist

The entries you make in the medical record should show you took appropriate actions in response to the patient’s condition. Record as close to the timing of the events as possible otherwise you

More info
Document What You Assess and What You Are Told
July 25, 2016

Document What You Assess and What You Are Told

Document What You Assess The first encounter with a patient usually includes obtaining a health history interview when you gather information about the patient’s current symptoms and past health

More info
July 18, 2016

Organize Your Entries

It is not always easy to make documentation a priority.  Time constraints may lead you to think that other patient care activities are more important, particularly in a crisis situation.  Often

More info