help !

  1. help !
    I am having the health assessment (lab exam)
    I need help on the documentions !!
    Its the head to toe lab exam ,, am I crazy ??
    or is it easier than I think it is ?? I am freaking
    out over this.
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  2. 8 Comments

  3. by   Love-A-Nurse
    originally posted by s.brown
    help !
    i am having the health assessment (lab exam)
    i need help on the documentions !!
    its the head to toe lab exam ,, am i crazy ??
    or is it easier than i think it is ?? i am freaking
    out over this.
    what don't you understand? i will help if i can.
  4. by   MelH
    :angel2: We're all here for you, S.brown. Lay it on us!! What can we help you with?
  5. by   S.Brown
    I guess I am freaking out over nothing ,but I cant seem to
    get the exact words right , I know its the nursing notes
    but I go blank on them when I am trying to write them
    for practice. We have a new instructor (first class) and
    I cant understand the documenting he wants. In class
    it sounds simple but at home I just cant get it, do you
    have ideals??
    Thanks
    Serena
  6. by   dstudent
    I'm not exactly sure what that is I'm sorry but I do wish you luck and I'm sure you'll do just fine
  7. by   MelH
    Serena, ask your instructor if they have the cd "chart smart" this is a really good cd on documentation. If they don't have it go up to your instructor and ask him what he wants and tell him you are a little confused. Nothing wrong with that and I am sure he will understand. Good luck!
  8. by   Mkue
    Are you having trouble documenting nursing notes? One of our instructors passed out a "sample" of how they wanted this done. Maybe you could get a hold of a sample to give you a better idea.

    Of course the more you do the better it gets !
  9. by   Katnip
    Every instructor likes things done a bit differently, but basically, for the subjective protion of the exam (the part where you ask patient the questions) you would wirte: patient reports/denies, smoking, pain, drainage, whatever.

    On the objective part, you write exactly what you see or don't see..."skin dry, intact, coloring consitent with racial background, absence of lesions, contusions, moles"

    Is that the kind of thing you're looking for?
  10. by   MelH
    HEY CYBERCAT ARE YOU CURRENTLY IN NURSING SCHOOL? IF SO WHICH ONE? I HAVE A FRIEND IN NURSING SCHOOL IN MD. SHE GOES TO CECIL COMM COLLEGE.

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