CHART SMART: Documenting general observations

February 2006 
Volume 36  Number 2
Pages 25 - 25
  PDF Version Available!

 YOUR GENERAL OBSERVATIONS of a patient's appearance, mobility, communication ability, and cognitive function are an important part of your initial assessment. For example, when documenting a patient's mobility, note whether he can walk and move independently or needs help, and whether he has weakness or paralysis.

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