physical assessments

How to Document a Physical Assessment?

Documentation is an integral part of the assessment process. Accurate and thorough documentation helps in continuity of care, legal protection, and communication among healthcare providers. Nurses should record their findings in a clear, concise, and organized manner, often using standardized forms and electronic health records (EHR). It is essential to include both objective data (measurable and observable) and subjective data (patient-reported).

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