You will complete a head to toe physical on a volunteer. You will need to record your assessment and then document your findings. General survey: state findings aloud Head Eyes Ears Nose Throat Neck Respiratory Cardiac GI/GU (do not assess their genitals) Musculoskeletal Neuro Before finalizing your work, you should:
Before finalizing your work, there are several important steps you should take to ensure that your assessment and documentation are thorough and accurate. These steps involve reviewing your findings, organizing your data, and performing a final check of your work. By following these steps, you can effectively complete your physical assessment and documentation.
Firstly, you should review your findings and ensure that you have assessed all the necessary body systems as per the assignment requirements. Double-check that you have examined the head, eyes, ears, nose, throat, neck, respiratory system, cardiac system, gastrointestinal and genitourinary system (excluding the genitals), musculoskeletal system, and neurologic system. It is crucial to ensure you have not missed any areas that need to be assessed.
Next, organize your data in a systematic manner. Create a clear structure for your documentation, starting with an introductory statement that summarizes the purpose of the assessment. Then proceed to record your findings for each body system separately, following a logical and sequential order. This organization will make it easier for readers to follow your assessment and understand your documentation.
Within each body system assessment, include relevant details such as inspection, palpation, percussion, and auscultation findings. Use precise and descriptive language to convey your observations accurately. When documenting abnormal findings, provide specific details such as location, size, color, shape, and any associated symptoms or discomfort. This level of detail will facilitate better understanding and interpretation of your assessment.
After organizing your data, perform a final check to ensure accuracy and completeness. Review your assessment documentation for any errors, inconsistencies, or missing information. Check that you have used correct medical terminology and abbreviations consistently throughout your work. Verify that there is a logical flow of information and that your findings align with your observations. Correct any mistakes or omissions promptly to provide a comprehensive and accurate assessment.
Additionally, consider reviewing your documentation from a holistic perspective. Reflect on the overall assessment and identify any patterns or trends that may be present in your findings. Look for connections between different body systems and assess how they may relate to each other. This holistic approach will help you develop a comprehensive understanding of the volunteer’s health status and enable you to provide more insightful and integrated analysis in your documentation.
Finally, ensure that your documentation is concise, clear, and easy to read. Use appropriate headings, subheadings, and bullet points to enhance readability and aid in information retrieval. Proofread your work for grammar, punctuation, and spelling errors. A well-organized and error-free document will strengthen the credibility of your assessment and demonstrate your professionalism.
In conclusion, before finalizing your work, it is essential to review your findings, organize your data, and perform a final check to ensure accuracy, completeness, and clarity. By following these steps, you can ensure that your physical assessment and documentation are of high quality. Taking the time to carry out these final steps will enhance the overall effectiveness of your work and contribute to a strong and comprehensive assessment.