Documentation Help

[waxman929]

I am in my 7th week of semester 1 of my adn program. we start system assessments on wed. and as of yet have had no real direction in documentation. Being as how it is 5o% of our check-off grade I am Kind of freaking out here. Does anyone know of any web sites that give examples and or direction into documenting? Any help would be greatly appreciated.

waxman929

[rpv_rn]

Link to site for Head to Toe assessment. Helpful information that can guide you in documenting your findings.

How To How to Perform a Head to Toe Assessment

http://nursing.about.com/od/assessmentskills/ht/headtotoeassess.htm

[Daytonite, BSN, RN]

also check out the link i am giving you to a forum thread on physical assessment. i just posted a bunch of websites on performing physical exams from medical school websites onto it. one of them

http://medicine.ucsd.edu/clinicalmed/write.htm is where you will find an lengthy explanation for medical students on how to write up a history and physical.

https://allnurses.com/forums/f205/website-help-physical-assessment-screening-physical-exam-145091.html#post1538265

http://listserv.acsu.buffalo.edu/cgi-bin/wa?a2=ind0602&l=carepl-l&t=0&f=&s=&p=305 go to this website and click on the link that says "final lithium toxicity profile.doc" it is a student care plan that was posted recently that includes documentation of the history and physical assessment of the patient. this will give you an idea of how the student presented her physical findings for her scholarly care plan.

http://go.dbcc.edu/hhps/nursing/files/3ebb3f625cc34c83a890073282d58319.pdf - a nice, simple physical assessment guide list from daytona beach community college nursing program in a pdf file.

[waxman929]

Thanks y'all. these are great sites and will help immensely! I appreciate the direction. Have a great day.