Documenting Respiratory, Cardiovascular and Neurological Systems

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 assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care….

Documenting GU, Skin and Reproductive Systems

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 assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient…

Documenting EENT, GI, and Musculoskeletal Systems

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 assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient…

Documenting Communication and Cognitive Function

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 assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient…

Documenting Appearance and Mobility

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 assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient…

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 the assessment process using the techniques inspection, palpation, percussion, and auscultation when examining the patient. Objective data is also referred to as “signs”. In medicine, a symptom…

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 the assessment process using the techniques inspection, palpation, percussion, and auscultation when examining the patient. Objective data is also referred to as “signs”. In medicine, a symptom…

Document What You Do Checklist

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 may not remember key points, times, or persons that are important to record.  Record “real-time” when documenting interventions.  Real-time entries may avoid…

Document What You Assess and What You Are Told

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 status, previous medical treatments, and responses to treatments or procedures.  This information is the basis for the formulation of the plan of care and the devising…

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 documentation is pushed to the bottom of the list of priorities.  To help prevent documentation from becoming a burden, organize patient care information into…