I'm feeling stuck we need to write about a physical assessment Keeping in mind including the caring curriculum holistic approach data collection (subjective obejective) the determinants of health and any special considerations that may be used ie:assessments of different age groups
head-to-toe physical assessment in a systamatic way I'm having trouble structuring this any help appretiated
Thanks Dinny Student LPN
Last edit by dinny on May 3, '05
May 3, '05
does anyone have the ans to this
May 3, '05
Im not an expert but I will try to help.(isnt that what nurses do?)
Subjective data: What the client says about his/her condition. Any statements they give you.
Objective data: What you see, smell, hear, feel or read including any measurements. (NO assumptions here) Do include past medical history in this section.
This sets you up nicely for Assessment and Plan of action.
I learned this format about 20 years ago--they called it SOAP notes.
May 5, '05
subjective what the patient states
objective what is Observed
make sure you document everything you done for that patient if it is not documented you didnt do it. If they complained of pain for instance did you give a prn pain med?things like that
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