Recording Patient Assessment Findings
Charting: Guiding principles:
- Describe any abnormality in full.
- 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.
- 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.
- 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.