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2. Physical Assessment Documentation Change Objectives. Define rationale for changes;Demonstrate how the changes to the physical assessment form support efficient and effective documentation;Explain how to use the revised edema and skin integrity grids.. 3. Rationale for the Change. The physical assessment form must capture positive and negative findings.The form should make it easier for the nurse to identify changes in patient status.These changes will support future system enhancements a32399
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1. Physical Assessment Documentation Change Tutorial PowerChartClinical Documentation
Summer 2008
2. 2 Physical Assessment Documentation Change Objectives Define rationale for changes;
Demonstrate how the changes to the physical assessment form support efficient and effective documentation;
Explain how to use the revised edema and skin integrity grids.
3. 3 Rationale for the Change The physical assessment form must capture positive and negative findings.
The form should make it easier for the nurse to identify changes in patient status.
These changes will support future system enhancements and the continued use of charting by exception (CBE).
4. 4 Charting By Exception (CBE) Charting by Exception is a streamlined format that is used to enable nurses to quickly and completely chart findings that match or deviate from Defined Normal assessment parameters.
5. 5 Each body system has a definition of Defined Normal located in the window (aka Genview) at the top of each body system form and/or section.
WDL (within defined limits) specifies the finding for each parameter that is considered normal.
Deviations from normal are documented using WDL Except and the exceptions must be specified.
Charting By Exception (CBE)
6. 6 Physical Assessment Form Changes: All defined normal parameters default to WDL.
This implies that the parameters of the system that were opened, were assessed, and found to be within defined limits.
If nothing is changed and the form is signed, the defined normal parameters for the system will indicate WDL on the flowsheet.
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9. 9 Nursing Flowsheet:
10. 10 Physical Assessment Form Changes (cont.): WDL Except and Additional Parameters remain unchanged.
Unable to Assess has been added to each defined parameter in each body system; if selected, a reason Unable to Assess is required.
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12. 12 Charting a Physical Assessment The following slides will demonstrate documentation on the physical assessment related to the changes that are being implemented.
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26. 26 Documenting a Selected Assessment Selected Assessment occurs when only one or some of the Defined Normal parameters have been assessed.
Selected Assessment may occur as part of the plan of care or per a physician order, such as a frequent assessment of LOC on the Neurological Form.
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31. 31 Form Change: Edema Grid The edema documentation grid has been changed; multiple rows have been added to eliminate the need to add new rows.
Review the reference text for appropriate definitions of edema, generalized edema and limited use of the term anasarca for end-stage system failure.
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41. 41 Skin Assessment Documentation The skin assessment documentation grid has been changed; multiple rows have been added to eliminate the need to add new rows.
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55. 55 Review of Documentation Changes All of the body systems defined normal parameters will default to WDL.
Signing the body system form without changing the default indicates that each Defined Normal parameter was assessed and found to be Within Defined Limits.
Edema and Skin Assessment documentation is completed on a grid.
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