How Do You Write A Physical Assessment?
Writing a physical assessment is the first step nurses take when collecting data on a patient. The assessment is done in writing because the results will need to be validated, organized, analyzed and then recorded on the patient’s chart. Nurses strive to obtain a complete health record before doctors perform an examination resulting in a diagnosis and suggested treatment plan. The two main types of data used by nurses to write a physical assessment are subjective data, which is collected from interviewing the patient and family members, and objective data, which is based on direct observation. Find out which type of assessment you must perform. For example, write “initial assessments” as soon as possible after the patient is admitted to the hospital. If you’re writing a “problem-focused assessment,” you must know what questions will help you determine the status of the problem the patient reported in the initial assessment. “Emergency assessments” are written immediately, usually as th
