Physcial Assessment

  1. Clinicals are starting!! Does anyone have any tips/pointers/sequences or ANY help with physical assessments!? And documenting? I know you can't document RIGHT away with an assessment, because maybe you have other thins you need to do.. So, what do you personally do? Keep it in a little notebook? On a notecard? I need help!! I know y'all have been through it &/or going through it!
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    About meachamkb

    Joined: Sep '12; Posts: 3; Likes: 1


  3. by   Still Standing
    Your clinical instructor will tell you every thing that is required of you. You will need a Pocket notebook to take notes, and record your VS and any other info you need. Just keep your notes organized and sequenced, your instructor will tell you what you are to do. Every school and site is different as far as assignments. I know how you feel, I just finished my clinical rotations last week for this semester (I'm in my first semester of LPN program have 2 1/2 weeks left till the end of this semester ) !, believe me after the first day, you will get the swing of things, and know what to expect and a better way of doing things, especially if you have a great instructor who critiques you on what you're doing. Good Luck!
    Last edit by Still Standing on Nov 13, '12
  4. by   Lovewhatidointx
    Depending on the facility you're at, most nurses have what we call our brain. It's a computer printed page that has the pt's name, diagnosis, etc. Ask the nurse for your assigned patient if you can copy hers. Don't be scared to ask. We were all student nurses at one time. Sit in with your nurse when she gets report & take notes on it. Then, write your assessment info on it. It will be a lot easier to keep up with one sheet of paper instead of a notebook. A piece of paper folds up nicely, fits on your pocket & can be put in a shred box when you're finished with it. A notebook can hold a lot of pt info & if you make the mistake of leaving it out, could get you in trouble if you have info on several patients in it. You will hear HIPAA until the day you retire. Better to develop good habits early. I don't know too many nurses who carry pocket notebooks on the floor because of this very reason. Our brains go in the shredder when we're finished with them. Or I should say, that's where they're supposed to go. Good luck!