Documenting Physical Assessment

[nic09]

I am a freshman nursing student and I need help on how to document a physical assessment check-off. Any pointers would be greatly appreciated.

[stressgal, RN]

The most important thing is to know your normals.

Attached is a sheet I put together when I first took physical assessment. It was a reminder to me so I didn't forget anything while charting. Maybe it will help.

Good Luck

WNL findings.doc

[Daytonite, BSN, RN]

Well, I'm being funny, but just check off the stuff that applies to the patient. These new charting by exception forms were developed to save the nurses time. In my day we had to do narrative charting and write everything out.

Seriously, you still need to know what a normal assessment should be so that you recognize when you find something abnormal. The problem with this check-off stuff is that it doesn't always have everything included on it. Therefore, I think it's a good idea for you to have some kind of guideline to carry around with you. Check things off as you can, but if you run into a situation where there isn't a box to check off for something that you found, there needs to be a way for you to write that in narratively. For years I carried around a laminated sheet that had a head-to-toe assessment on it that I could refer to.

You can find all kinds of information on assessment in the health assessment resources, techniques, and forms thread of this forum. Here is a link to it:

https://allnurses.com/health-assessment-resources-techniques-forms-t106551/

You may have to create your own little form to use. There are plenty of links in there for you to use for reference. This thread is also a sticky which means that it appears at the very beginning of all the listings for this forum all the time. There is also an assessment form in the middle of taber's cyclopedic medical dictionary under the listings for "Nursing".

It would also be a good idea to try to get a blank form that you will be using at the nursing facility you will be doing your clinicals in so you can get familiar with the form you will be using. Every facility also has a guideline (instructions) on how each of their forms is to be used. You would find out about that through their nurse educator.