How do nurses document findings from a physical examination?
Documentation is a critical aspect of the nursing process. Nurses should record findings accurately and comprehensively in the patient's health record. This may include normal and abnormal findings, the patient's subjective complaints, and any interventions or further assessments required. Proper documentation ensures continuity of care and serves as a legal record of the patient's health status and the care provided.
In conclusion, a detailed physical examination is an integral part of nursing that requires skill, knowledge, and sensitivity. By understanding its components, techniques, and challenges, nurses can perform thorough assessments that contribute to high-quality patient care and outcomes.
