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For assessments I have found the Nurse's Handbook of Health Assessment by Janet R. Weber to be both informative and helpful. It is a small, portable, binder size book covering your head-to-toe assessment. It has graphics, tells you what to look for, and reminds you of whether your observations are normal or a deviation thereof.
As for documentation, I have not yet found a good one myself. I've used my Foundations of Nursing book by Kozier as a reference which is helpful but not all that indepth. But it covers the do's and don'ts of basic documentation.
the best book i've ever had for physical exam and actually used as a practicing nurse over the last some years was mosby's expert 10-minute physical examinations which i bought sometime back around 1998 or 1999 when i was working in a nursing home. i have often used it to answer physical exam questions that have come up on this forum. (see http://allnurses.com/forums/f50/abdo...on-189688.html for a discussion about percussing the abdomen and the difference between dull and flat sounds) it is, i see, still in publication although updated and the same formatting seems to have been retained in the updating as well as the editor has now been identified (cindy tryniszewski, rn msn). its current cost is $42.95.
the other book i consult a lot is a medical student textbook entitled textbook of physical diagnosis: history and examination, third edition, by mark h. swartz which is no longer in publication with the last edition having been published in 1998. however, much of the pertinent information in this book can be found for free online at many of the medical school assessment websites along with photos (and some have videos) listed on the sticky health assessment resources, techniques, and forms in nursing student assistance forum http://allnurses.com/forums/f205/hea...ms-145091.html. the medical school assessments take medical disease into account during abnormal assessment and not all nursing assessment texts cover that aspect as thoroughly.
allnurses also has a sticky on documentation in this forum. i do not have a book to recommend on this, as it was never an issue for me in my practice. i was always taught to chart objectively and chart what i saw. learning good assessment descriptions of many things you are looking at and describing helps and this is something you learn over the years. i read doctor's history and physical exams, procedure and operative reports of my patients as a regular routine and you pick up a lot of descriptive terms from these documents. i came into nursing at a time when all charting was narrative and there was none of this charting by exception and check-off stuff. i've posted examples of the different types of documentation in the documentation sticky i've listed below. the first physical exam weblink from ucsd above includes a section on writing up the "findings" of a physical exam. much of this is knowing how to describe in medical terminology what you have observed.
Hi Daytonite... an instructor just recommended the Mosby's expert 10 minute examination book (mainly to use on our upcomming test) and I just wanted to get your opinion on whether you think it would be crutial to get the newer version??? Or do you think the old version would work? I'm, of course, a broke nursing student. hehe
i don't know if you can even get the older version, can you? assessment doesn't really change much from year to year. i haven't seen what is in the new edition, so i couldn't tell you what has been added. basics are still basics.
there is a lot of basic stuff in the two medical school assessment websites on the internet: