do a complete head to toe assessment? What are things you ALWAYS assess? I've been told by patients that I'm the first to listen to them with a stethoscope. How do you document when you did not do a complete assessment on an area (ex. deferring a reproductive exam on an appy pt)?
I have a list of always assess things - cardiac/lung/bowel sounds, radial/pedal/post tibial pulses, sensation, basic neuro status, access device, pain. Then focus on whatever the problem is and assess that.
just curious on everyone's practices.