Recording Patient Assessment Findings

 

Charting: Guiding principles:

  1. Describe any abnormality in full.
  2. Describe normal findings when pertinent to pre-existing conditions that may promote the formation of abnormalities – “no heamorrhages or exudates of retinal vessels” when pt has Hx of HTN.
  3. Keep in mind that data not recorded is data lost – our ability to recollect weeks or months down the road is impaired from clarity of the day of the encounter.
  4. call attention to the most important information first, so as not to bury it in a sea of details.

Bates, Barbara. 1974. A Guide to Physical Examination. J.B. Lippincott Company, Toronto.

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