Card Set Information
Data Collection assessment
4 steps for assessment
Sources of Data
*client, family and significant others, client records, medical records, labratory records, literature
A. Before seeing person....
B. When seeing person...
C. After seeing person...
A. get information you can, may be only name or may have chnce to look at previous records
B. Interview and physical exam
C. Need to review information and then may need to consult other health team members (clarifying)
Types of Assessment:
B. Problem Focused
A. Comprehensive; covers all aspects of the client; use all sources; usually have a printed form to follow
B. thorough in a specific area; when you see a problem while doing a complete data colection or to monitor specific problems during care, then you focus on that area
General Information...name 3 criteria
1. Data should be descriptive, concise, and complete
2. As you are asking questions and getting answers, you should be anticipating what other data you'll need in relation to the previous question
3. Your entire plan of care will be based on this information.