All the terminology used should be appropriate. Correct spellings are also necessary and conclusions must not be vague. Moreover, consistency in charting the medical record is necessary. The workups should follow the accepted documentation standards. All the test results and treatment programs entail logical presentation. In addition, objectivity throughout the gathering and interpretation of facts is very important (Marcinko & Hetico, 2011).
Typed notes are mostly preferred but not mandatory. The medical record should read as if the documentation was meant for a third party. Therefore, everybody should be able to read the handwriting. If there is a mistake in the records, one should struck through the error once and then initial his/ her name. The errors are not supposed to be erased, scratched out or blacked out. One should not write on the margins as well. The chart should appear orderly, clean and professional (Marcinko & Hetico, 2011).
Both the art and the science of nursing is essential in conducting health assessments and physical examinations. Critical thinking and clinical reasoning are essential in physical assessment of a patient (Estes, 2013). When conducting a physical exam, noting the vital signs is important in giving clues to the individual’s overall health. The lung and thorax examination should include an assessment of any allergy symptoms experienced by the patient. Chest examinations include assessment of breathing sounds. The respiratory rate and the rhythm are also examined. The skin may be examined to find out if an allergic component is at work using evidenced by presence of a rush. Moreover, it is very important to measure the volume of air going in and out of the lungs, the speed of movement of the air and the volume of the air that is moving to identify or rule out other respiratory disease (Clark, 2011).
Pre and post bronchodilator tests entail proper application to rule out more respiratory maladies. The patient completes a basic ...
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