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Please help w/ Head to Toe Assessment

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by LPNin11 LPNin11 (New) New

OK here is my problem. We are currently working on h2t assessments. I know how to do them. I need a bit of help finding a work sheet to write my finding on. The one we use really really confuses me. I also need to know if you chart the things you check that are NOT abnormal. They say "if it is not charted, it is not done" but if nothing is wrong with say his ears, well then what do you put?

TIA

UM Review RN, ASN, RN

Specializes in Utilization Management.

If you write all the things down that are NOT wrong with a patient, you'll surely drive yourself crazy by writing reams of unnecessary information!

We use a format called "exception charting" which means that you only chart what's abnormal. We use a combination of flow sheet and progress notes.

If we check something as "abnormal" on the flow sheet, we follow up with a written nurse's note.

Way easier.

You might even be able to Google up some flow sheet forms to help you get a format going.

If you write all the things down that are NOT wrong with a patient, you'll surely drive yourself crazy by writing reams of unnecessary information!

We use a format called "exception charting" which means that you only chart what's abnormal. We use a combination of flow sheet and progress notes.

If we check something as "abnormal" on the flow sheet, we follow up with a written nurse's note.

Way easier.

You might even be able to Google up some flow sheet forms to help you get a format going.

Thank you so much!! Ill check it out!!

lil' girl, LPN

Specializes in LTC. Has 4 years experience.

If you write all the things down that are NOT wrong with a patient, you'll surely drive yourself crazy by writing reams of unnecessary information!

We use a format called "exception charting" which means that you only chart what's abnormal. We use a combination of flow sheet and progress notes.

If we check something as "abnormal" on the flow sheet, we follow up with a written nurse's note.

Way easier.

You might even be able to Google up some flow sheet forms to help you get a format going.

Yup that's the way we are learning too, except ours is called "charting by exception".

mitchsmom

Specializes in OB, lactation.

We do not chart by exception but I wish we did!!

We can't say an item was "normal" - we have to be very specific.

For example, if the skin looks "normal", it is pink, no pallor, no tenting, no edema, etc. I usually end up with a big list of "no's" - on some items I have even written:

No: heaves, lifts, thrills, thrusts, murmurs, etc. etc. etc. blah, blah, blah, on, and, on...

I am still learning how to document, sometimes it is helpful for me to see what others have written in the nurses notes, history, etc. in the chart.

manna, BSN, RN

Has 6 years experience.

We're learning how to chart by exception as well, but for our clinical course purposes, we have to fill out head-to-toe worksheets for client assessments and care plans.

If you'd PM me, I'd be happy to share some of the forms that we use (most are .doc format)

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