The Health Assessment

Question 1

Standard Assessment

Answer 1

• Inpatient care: every patient / every shift; some patients/multiple times per shift; focused assessments when something is not right
• Outpatient care / clinics / community / etc: based on the reason for the visit; mostly focused assessments

Question 2

Documentation of Findings

Answer 2

• As soon as you can after finishing assessment

- Don’t think you will remember: one patient vs 4 patients; changes happen!; no documentation? NOT DONE

Question 3

Med administration checklist

Answer 3

1. Check orders / MAR
2. Verify all medication orders are complete and make sense
3. Look up what the drug is for and why are they on these drugs
4. Could you tell me your date of birth, I’m here to give you your 9 o clock meds - can you take them all at once or do you need them one at a time