Assessments in ambulatory care/outpatient infusion

[RNSueVA]

I'm interested in knowing what type of assessments are required in your outpatient setting. Are you required to do daily body system assessments? Braden scores? Falls risk assessment? Does it change based on the patient? For example, daily antibiotic patient versus bi-weekly Procrit patient?

[brownbook]

We have a nursing H & P simple checklist with yes no answers, get vital signs. We do not do a full body assessment.

We assess more thoroughly as their presentation might warrant.

If something stands out, for example, wheezing, coughing, fever, history of asthma, we would listen to their lungs. But if they are in "no apparent distress" vitals stable, condition unchanged from their last visit. We do not do a through head to toe assessment.

[mappers]

We do symptom assessment more than sign assessments. Always do weights, v/s. If a patient is on Chemo, we ask about s/e, n&v, pain, mouth sores, constipation, etc. We might look at the mouth. If pt c/o soa or cough, we might listen to lungs. No braden scores, no falls risks, etc. For a Procrit, it is abbreviated, basically a how are you feeling, any problems, and probe the answers. If they say they feel pretty well, then that's about it.