Head to Toe Assessments

  1. Hello all =)

    I'm wondering if anyone knows a website where I can find the terms used when doing the head to toe assessment documentation? For example under skin: intact, not intact, dry, rough, etc. I'm doing my assessments and want to make sure that the terms I use for documentation will make sense when my instructor reads my charting.

    Thanks!
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  2. 4 Comments

  3. by   Daytonite
    http://www.mededcenter.com/module_vi...+118#headtotoe - this is a great guide to physical assessment. it is called head to toe assessment in 5 minutes (well, maybe a little longer than that)

    http://medicine.ucsd.edu/clinicalmed/introduction.htm - a very nice site to help with doing physical assessments of patients from the university of california, san diego. explains how to examine the various parts of the body and has lots of photographs showing abnormal conditions and how to assess for them. click on "write ups" to see two examples of how to write up h&p findings.

    you should also check out the links on this thread:
    http://allnurses.com/forums/f205/hea...ms-145091.html - health assessment resources, techniques, and forms (in nursing student assistance forum)
  4. by   dotscan
    IHello Everyone!
    Thanks for the physical assessment site. It will guide me for my presentation.
    Dotscan
  5. by   Daytonite
    just found this webpage this morning. i think this is what you are looking for.

    http://www.stbarnabashospital.org/fp/sampleh&p.doc - this is a guideline as to how the results of a history, review of systems and physical examination should be written up.
  6. by   Lisa CCU RN
    These websites are great, Daytonite!

    You, alone, are gonna be the reason I excel in nursing school.

    Thanks for all the great information.

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