Would you put not assessed, or would you put no abnormalities since you didn’t visualize any?This is probably a question you should address by re-reading the initial assessment (or primary assessment) chapter in your textbook.
Short answer - if a patient can cogently express their concern and you see no life threats or apparent other problems, a focused assessment is appropriate. There’s not really a need to fully expose and head-to-toe assess a patient who is A&Ox4 and clinically stable complaining of isolated tooth pain or pharyngitis.
How do you know there are “no abnormalities “ if you didn’t assess? You’ve just lied on a medical document.Would you put not assessed, or would you put no abnormalities since you didn’t visualize any?
Unless I had some reasonable suspicion to check, my narrative would state the patient had no complaints related to those other areas. Depending on the charting system, you might mark not assessed or just not note anything at all.Would you put not assessed, or would you put no abnormalities since you didn’t visualize any?
This is where you have to start thinking about your patient, their complaint, and what's relevant to their situation. If you're going to mark something as "not assessed" you should have something in your narrative that explains why you didn't assess that. If you're marking "no abnormalities" then you've assessed that and you'd better have done so otherwise you've just lied on a legal document.Should you do a full head to toe on every patient including medical patients? If you do not, should you mark "not assessed" or "no abnormalities" since you can visualize without touching and removing clothing?