Part III Recording the Physical Assessment Findings
As an introduction to charting, it should be known that there are many different ways to record an assessment. Some hospitals have their own form for recoding findings, and other facilities, a narrative or “story” form. This guide for charting will present one method. If your facility uses a different method of charting, you may still derive some benefit from this exercise. You can study terminology and the presentation, and then apply it to your facility. Even if your facility uses a “checklist” style charting, you still may have to have to record certain observations that do not exactly fit those checklists. Therefore, remember to observe and carefully describe and record your findings for each patient.
Vital signs, radial pulse, BP, temperature, respirations, and history. “Patient is a 78 year old mail, in no acute distress, reports a “heart attack” 5 years ago and has been in good health since then; came into the ER today feeling weak, dizzy, and pounding in the chest.”
Next the general medical exam:
Patient is alert, oriented, no respiratory difficulty, no complaints of pain now, skin turgor good, skin color good, skin is warm and dry, no problems voiding, and no bowel movement for 2 days. Takes Dioxin and Lasix QD, dosage unknown, lungs sound slightly congested but no dyspnea, as stated above.
Peripheral pulses all present and strong, neck veins slightly distended when laying down, heart rate regular and strong, thorax normal shape, no masses, no tenderness, heart sounds clear and strong, with faint murmur between INSERT S1 and , sounds like clicking noise, MD was notified, no treatment because patient has had condition for many years.
This is a sample of a fairly healthy patient. Some facilities might want the cardiovascular system charted first in the nurse’s notes section. Others will want all cardiovascular findings together in one place o the chart. In the above example, we placed skin color together with the other skin findings. Skin color could be considered a cardiovascular sign. It does not matter where you put it; just remember to include all pertinent findings. How do you know what is pertinent? That is a difficult question, but always remember to include all findings that you would expect to be abnormal if the patient did have a definite cardiovascular problem.
Assessments such as skin color, respiratory difficulty, poor pulses, poor heart sounds, and low BP, etc. this is why it is important to have the history and the general medical exam reviewed by the nurse before you concentrate on your cardiovascular exam. Once you know general findings, it is easier to review the cardiovascular system.
As you finish recording your findings remember to include all actions that you took for your patient. If you start your exam and the patient was having a severe asthma attack, you would say, “wait,” I have to do my cardiovascular assessment first. You would take the appropriate emergency measures first. Remember to chart all such treatments for emergency measures. Legally, you might be held responsible, even if you did take appropriate measures, if you did not chart “notified MD” you could be responsible for some adverse occurrence.
Charting is a method of recoding that you did take the appropriate action for the situation; “notified MD and no treatment at this time.” this charting protects the patient, and protects the nurse. It lets everyone know that you performed the correction action in response to your abnormal findings. If you are ever in doubt as to how you should chart something; remember to be as objective as possible. Chart the findings (be descriptive), and then chart what you did about it. That is how good charting protects you and the patient.