Documenting EENT, GI, and Musculoskeletal 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
Eyes, ears, nose, and throat
After examining the eyes, ears, nose, and throat, document the following:
Assessed	The patient’s ability to see objects with or without corrective lenses as appropriate
Assessed	The patient’s ability to hear spoken words clearly
Inspected	The patient’s eyes and ears for discharge; the nasal mucous membranes for dryness, irritation, and the presence of blood; and teeth for cleanliness
Assessed	How well the patient’s dentures fit, if appropriate
Assessed	The condition of the oral mucous membranes
Palpated	The lymph nodes in the neck
Gastrointestinal system
After examining the gastrointestinal system, document the following:
Auscultated	For bowel sounds in all quadrants
Assessed	For abdominal distention or ascites
Palpated	The abdomen to assess for tenderness
Musculoskeletal system
After examining the musculoskeletal system, document the following:
Assessed	The range of motion of major joints
Assessed	For swelling at the joints
Assessed	For the presence of contractures, muscular atrophy, or deformities

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!