Going to ER from ICU. Help! - Page 3

You can also chart a quick assessment. For example, for SionainnRN’s hypothetical pt c a broken vs. strained ankle, you could note, "Well oriented and speaking clearly and appropriately. Respirations regular and unlabored. Skin warm and dry. Denies any complaint or medical problem other than the pain in his ankle."

O.K. O.K. I know that I am gonna get flamed because of the superficiality of my assessment, and I probably deserve it. (Exactly what does "speaking appropriately" really mean?). However, this note would record the fact that I was attentive to the possibility of additional problems in other organ systems, and honestly indicate what lead me to the conclusion that more detailed assessment could be safely deferred.

Just throwing this out there for discussion; not claiming to be right.

I think that is a fine thing to document. It indicates a basic assessment of neurological, respiratory, and circulatory status. Had your basic assessment revealed anything outside of normal limits, surely you would assess further.

I usually word it a bit differently (for example, "answering questions appropriately), but I think this it a legitimate part of a neuro assessment.

It is a bit of charting a normal, but, in cases of stroke w/u, this is a pertinent normal. You would certainly chart that they "inappropriately answer questions" if they said Teddy Roosevelt is the current President or if they answer the question "where are you know?" with "hamburger."