physical assessment

Does anyone know where I can get any printable tools to help me flow through my physical assessment? I have looked at pocket guides but they are so expensive. How do you do an assessment that really flows smoothly for you and the pt. Also once I get the data How do I know what is important to include in charting and what is not.

Normally what most of us RNs have done is develop our own over years of practice. And most of us kind of have the sequence memorized in our heads. In my BSN program one of our assignments was to develop our own assessment guide. Over the years you will pick up little things you will want to add to the way to do your assessments. For many years I had mine on one piece of paper that I covered with clear contact paper and kept on my clipboard. At one point it became so cluttered with things I had added with magic marker (because ink doesn't work on clear contact paper) that I re-typed it.

You start by listing the 11 body systems. Under each, list items you feel are important to address for that particular body system. Add items from reviewing notes from your physical assessment class (if you had one). The next time you are in the clinical area, pull the nursing policy and procedure manual and look for the p&p for admission procedure because it might list out specific body areas to be assessed. Also, ask the unit secretary if you could have a blank admission assessment form because there will be things on it that you may want to include on the guideline you are developing for yourself. Read doctor's H&Ps as often as you can to get an idea of the kinds of things they address in their assessments. You may also find a guideline for assessment in the doctor's dictation area. Many medical records departments develop a template to help the doctors remember what they need to put in their H&Ps and they put it right by the phone the doctors use for dictation.

You bring up a point that I had kind of forgotten about. We were told long ago in my physical assessment class to try not to make it look too obvious that we were reading from a piece of paper and asking the questions on the paper when doing the patient assessment. It irks the patients and makes them feel like they're just another body in the system. So, what I've done over the years is talk with the patient as I'm admitting them. If I notice something about their physical appearance I'll ask about it. While I'm asking about that area of the body it also triggers in my mind to ask about any related areas of the body as I'm talking to them. So, while I'm getting them settled in the bed, covers pulled up, rearranging overbed table or IV pole, I've already started my assessment. Then, at some point, I'll look at the assessment form to check to see what I've forgotten to ask about or check. I've done this so much that I can usually do a quick head to toe review in my mind and pretty much know what I've forgotten to address. This way the patient gets more of an impression that we are talking rather than filling out a questionaire. It took me some time, however, to be able to do this. If I discover that I missed a question or two when I am sitting down and charting, I'll make a note on my paper and the next time I'm in the room with the patient I'll say, "oh, by the way. . ."