How to Document a Physical Assessment

Nurses are often responsible for physical assessments.

A physical assessment is done at a doctor's office or hospital as either part of an annual visit or when someone enters the hospital with a health concern. While each hospital or doctor's office may have its own charts or lists of things to cover, there are a few things you must document when completing a physical assessment.

Instructions

1. Obtain the patient's name for the physical assessment form. Make sure to include the date. Depending on your procedures, you may also need the patient's address and insurance information.

2. Gather the patient's vital signs. Include her blood pressure, heart beats per minute, height and weight.

3. Note any abnormalities that may need extra attention.

4. Ask what brings the patient to the hospital or office. If the patient is complaining of pain, ask where the pain is located.

5. Ask how long the pain lasts and how often it occurs. Gather as much information about the pain as possible, such as the type of pain (sharp, dull, aching or burning) and how intense it is.

6. Ask the patient if he is aware of what triggers the pain and how he can relieve it, if possible. This can help identify where the pain comes from, such as withdrawals, restlessness, skeletal muscle tensions, nausea, stress or weakness, for example.

7. Ask any other questions that your office's intake or physical assessment form may require. For example, if the clinic focuses on feet, there may be specific questions or concerns that need to be addressed.

8. Make a copy of the physical assessment, and place it in the patient's file. If there are abnormalities or symptoms that need to be addressed immediately, contact the doctor who is in charge or on duty to inform her of the patient's symptoms.

References

• Scribd: Introduction to the Physical Assessment
• AETC National Resource Center: Initial Physical Examination