Document What You Assess and What You Are Told

Document What You Assess

The first encounter with a patient usually includes obtaining a health history interview when you gather information about the patient’s current symptoms and past health status, previous medical treatments, and responses to treatments or procedures.  This information is the basis for the formulation of the plan of care and the devising a teaching plan appropriate to the patient’s health literacy level.  The primary source for this information is the patient, however when the patient is not able to provide reliable information or is incapacitated, the next best source may be immediate family members and the previous medical chart if the patient if available.  If you are able to speak with the patient, use quotations to describe the patient’s symptoms, avoid interpreting what they say.  This helps to clearly differentiate yours words from the patient’s words. 

The first encounter with a patient usually includes obtaining a health history interview when you gather information about the patient’s current symptoms and past health status, previous medical treatments, and responses to treatments or procedures.  This information is the basis for the formulation of the plan of care and the devising a teaching plan appropriate to the patient’s health literacy level.  The primary source for this information is the patient, however when the patient is not able to provide reliable information or is incapacitated, the next best source may be immediate family members and the previous medical chart if the patient if available.  If you are able to speak with the patient, use quotations to describe the patient’s symptoms, avoid interpreting what they say.  This helps to clearly differentiate yours words from the patient’s words.  

The information you collect from performing your physical assessment includes vital sign measurements, inspection, palpation, percussion and auscultation.  Abnormal findings should be described in detail as they relate to the patient’s current condition.  It is also important to record the patient’s denial of symptoms that would be of concern as related to the patient’s current diagnosis or condition, for example, a diagnosis of myocardial infarction and denial of symptoms of chest pain.  These are what could be called pertinent negatives. 

Use objective terms and be specific to avoid making judgments of assessment data.  For example, “The patient’s urine output was only 90 ml,” this may suggest you think the urine output was too low.  Quantify your findings whenever you can by specifying numbers, ranges, degrees of elevation, temperature of heating or cooling blanket, or aqua K pads etc.  Phrases like “a little”, “a lot”, "appears", "fairly well", etc. leave ample room for wide interpretation, so avoid using them. 

Describe first-hand knowledge which means what you see, feel, smell, and hear during your assessment.  Avoid documenting your interpretation of patient behavior.  For example, document “Sarah was crying during the assessment” instead of “Sarah was crying during the assessment because she is depressed.”

Document What the Patient Tells You

The first encounter with a patient usually includes obtaining a health history interview when you gather information about the patient’s current symptoms and past health status, previous medical treatments, and responses to treatments or procedures. The information should be verified as understood so misunderstandings are less likely to occur.  This information is the basis for the formulation of the plan of care and the devising a teaching plan appropriate to the patient’s health literacy level. The primary source for this information is the patient, however when the patient is not able to provide reliable information or is incapacitated, the next best source may be immediate family members and the previous medical chart if the patient if available. If you are able to speak with the patient, use quotations to describe the patient’s symptoms, avoid interpreting what they say. This helps to clearly differentiate yours words from the patient’s words.