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.
Guidelines for General Observations
|After examining the genitourinary system, document the following:|
|Assessed||For bladder distention or incontinence|
|Inspected||The genitalia for rashes, edema, or deformity, if indicated. (inspection can be waived as appropriate)|
|After examining the integumentary system, document the following:|
|Inspected||The patient for sores, lesions, scars, pressure ulcers, rashes, bruises, or petechiae. Record on the skin assessment form upon admission.|
|Assessed||The patient’s skin turgor.|
|After examining the reproductive system, document the following:|
|Inspected||The genitalia for sexual maturity and abnormal discharge, if indicated|
|Performed||A breast examination, if permitted, and whether you found abnormalities|
Top 5 Malpractice Claims Made Against Nursing Professionals
Chances are at some point in your career, you will either:
- Have a claim made against your professional services.
- You will be named in a group lawsuit – whether as part of a larger group of health care professionals and/or included with your health care facility.
- Witness a negligent act by another health care professional during the course of a normal work day.
- Be deposed to testify on behalf of yourself, your employer or colleague.
No matter what the situation, being involved in any allegation of malpractice can be emotionally and financially devastating for all parties. However, if you are specifically named in the malpractice suit, your asset, reputation and career could all be in jeopardy. It is important to understand the most common allegations and how they happen in order to minimize your risk. Most malpractice calms involve at least one of the following allegations:
- Failure to follow standards of care
- Failure to use equipment responsibly
- Failure to document
- Failure to assess and monitor the patient
- Failure to communicate.