Documenting Respiratory, Cardiovascular and Neurological Systems

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function.  Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care.  

Guidelines for General Observations
Respiratory system
After examining the respiratory system, document the following:
Assessed	Rate and rhythm or respirations
Auscultated	The lung fields
Inspected	Sputum for color, consistency and other characteristics.
Cardiovascular system
After examining the cardiovascular system, document the following:
Auscultated	For heart sounds
Assessed	Heart rate and rhythm
Assessed	The color and temperature of the extremities
Assessed	The peripheral pulses; record the quality by “number”
Inspected	For edema (pitting; record by “number”)
Inspected	The neck veins (distention)
Neurological system
After examining the neurological system, document the following:
Inspected	The patient’s head for evidence of trauma
Assessed	The patient’s level of consciousness, including orientation to time, place, person and situation
Assessed	The patient’s ability to follow commands
Assessed	The patient’s pupillary reactions and cranial nerve function
Assessed	The patient’s extremities for movement and sensation

Top 5 Malpractice Claims Made Against Nursing Professionals

Chances are at some point in your career, you will either:

• Have a claim made against your professional services.
• You will be named in a group lawsuit - whether as part of a larger group of health care professionals and/or included with your health care facility.
• Witness a negligent act by another health care professional during the course of a normal work day.
• Be deposed to testify on behalf of yourself, your employer or colleague. 

No matter what the situation, being involved in any allegation of malpractice can be emotionally and financially devastating for all parties.   However, if you are specifically named in the malpractice suit, your asset, reputation and career could all be in jeopardy.  It is important to understand the most common allegations and how they happen in order to minimize your risk.  Most malpractice calms involve at least one of the following allegations:

1. Failure to follow standards of care
2. Failure to use equipment responsibly
3. Failure to document
4. Failure to assess and monitor the patient
5. Failure to communicate.

I will discuss these five common allegations in the coming blog posts, so stay in touch!