PHYSICAL ASSESSMENT

• one of the most important responsibilities of all health care providers. means of communicating among healthcare team members.

  DOCUMENTATION
• gathered during the health history and physical examination should be complete, accurate picture of the patient’s health state.

  DOCUMENTATION OF ASSESSMENT DATA
• study of a whole person, covering the general health state and any obvious physical characteristics. It is done before physical examinations.

  GENERAL SURVEY
• used to form a general survey of the whole person, not just to one body system

  OBJECTIVE PARAMETERS
• FOUR AREAS OF GENERAL SURVEY

  physical appearance, body structure, mobility, and behavior
• the act of “double-checking” or verifying data to confirm that it is accurate and factual.

  VALIDATION
• subjective or objective data that can be directly observed by the nurse; that is, what the client says or what the nurse can see, hear, feel, smell or measure.

  CUES
• nurse’s interpretation or conclusions made based on the cues;

  INFERENCES
• Conditions that require data to be rechecked and validated includes:

  Discrepancies or gaps between the subjective and objective data. Discrepancies or gaps between what the client says at one time versus another time. Findings that are highly abnormal and/or inconsistent with other findings
• Guidelines in Validating Data:

  Compare subjective and objective data. Clarify any ambiguous or vague statements. Be sure your data consist of cues and not inferences. Double-check the extremely abnormal data
• anything written or electronically generated that describes the status of the client on the care or services

  DOCUMENTATION
• Written Evidence of:

  interactions between and among health care professionals. administration of tests. results or client’s response
• documentation confirms the care provided to the client and clearly outlines all important information regarding the client

  COMMUNICATION
• Records are considered legal or potential legal documents

  Practice and Legal Standards
• Legal Aspects of Documentation Requires:

  Writing legible and neat Spelling and grammar properly used Authorized abbreviations used - Time-sequenced factual and descriptive entries
• government requires monitoring and evaluation of the quality and appropriateness of care provided.


  REIMBURSEMENT
• health care student use medical records as a tool to learn about disease processes, nursing diagnoses, complications, and interventions

  EDUCATION
• The client's medical record is used by researchers to determine whether a client meets the research criteria for a study

  RESEARCH
• documentation is used to evaluate the quality of care

  Nursing Audit
• It is called a nursing admission or admission database.

  Initial Assessment Form
• Four types of frequently used initial assessment documentation

  openended, cued or checklist, integrated cued checklist, and nursing minimum data set
• CALLS FOR NARRATIVE DESCRIPTION OF PROBLEM AND LISTING TOPICS PROVIDES LINES FOR COMMENTS INDIVIDUALIZES INFORMATION PROVIDES "TOTAL PICTURE"

  OPEN-ENDED FORMS (TRADITIONAL FORM)
• STANDARDIZES DATA COLLECTION LISTS INFORMATION THAT ALERTS THE NURSE TO SPECIFIC PROBLEMS OR SYMPTOMS USUALLY INCLUDES COMMENT SECTION

  CUED OR CHECKLIST FORMS
• IT COMBINES ASSESSMENT DATA WITH IDENTIFIED NURSING DIAGNOSES HELPS CLUSTER DATA, FOCUSES ON NURSING DIAGNOSES, ASSISTS IN VALIDATING NURSING DIAGNOSIS IN LABELS

  INTEGRATED CUED CHECKLIST
• Various institution has created flow charts that help staff record and retrieve data. Progress notes may be used to document unusual events,

  Frequent or Ongoing Assessment Form
• usually abbreviated versions of admission datasheets, with specific assessment data

  Focused or Specialty Area Assessment Form
• traditional format used for recording data in the medical record. the “source” or individual providing the data enters the information


  SOURCE-ORIENTED MEDICAL RECORD
• Charts in which the SOMR format

  Admission sheet, Initial Nursing Assessment, Graphic Record, DAILY RECORD, Special Flow sheets, Medication Record, Nurses’ Notes, Medical History and Physical Examination, Physician’s Order Form, Physician’s Progress Notes, Consultation Records, Diagnostic Reports, Consultation Reports & Client Discharge Plan and Referral Summary
• Findings from the initial nursing history and PA

  INITIAL NURSING ASSESSMENT
• VS; daily weight; special measurements such as fluid I & O

  GRAPHIC RECORD
• Activities; diet; bathing elimination records

  DAILY RECORD
• fluid balance records; skin assessment

  SPECIAL FLOW SHEETS
• Name or initials of person administering meds

  MEDICATION RECORD
• Pertinent assessment of client

  NURSES NOTES
• Past and family medical history; findings of physical examination by the primary care provider

  Medical History and Physical Examination
• Medical orders for medications, treatments

  PHYSICIAN'S ORDER FORM
• Medical observations; treatments; client progress

  PHYSICIAN'S PROGRESS NOTES
• Physical therapy; respiratory therapist

  CONSULTATION RECORDS
• Labs; x-ray, etc

  DIAGNOSTIC REPORTS
• Physical therapy; respiratory therapist

  CONSULTATION REPORTS