assessment paper

[becky5438]

I'm sure someone else has had to do one. Mine involves a complete medical history from patient and medical charts. relevant meds for each system, risk factors from lifestyle, orders(activity,scd's etc)grid, reason for diet ordered. 24 hour diet plan, medcards, and probably about 10 other things I can't think of without the paper in front of me. Does anyone have any suggestions to tackle this beast. I got alot of info from the patient, my medcards are done, but I have so much left to do. I have a schedule set for this week, I just don't want it to come down to the last second to finish it. how have other people handled these kinds of assignments. thanks

[Daytonite, BSN, RN]

you can see examples of medical write ups of history and physical exams on this website: http://meded.ucsd.edu/clinicalmed/introduction.htm - practical guide to clinical medicine. click on the "write ups" link.

[J9G2008]

Um, my "system" consists of writing lots of little notes all over my worksheet at clinicals, then flipping madly through all of it when it's time to do my assessment paper. One thing I was taught in second semester was to write a complete "normal assessment" then change the info for my particular patient. Like, under gastrointestinal, "oral mucosa moist and intact, teeth present, no dentures, no lesions in oral cavity", etc, etc. Only change that info if your patient is different. It saved me a lot of time over the past year.