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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.