Question

ATI Health Assess Debriefing Questions- Harold Stevens

1. What subjective data did you collect prior to beginning the physical assessment?
2. What objective data did you collect during the physical assessment?
3. What did you chart in the EHR?

Answer 1

1.Prior to beginning of the physical examination the subjective data collected is the Historyof the cilent. It includes all personal data including name, age, sex,marital status,occupational status,phone numberetc and next includes the chief complaints of the patient and its duration. then regarding the medical history and surgical history of present and past and family history to identify any predisposing factors genetic factors.then regarding the personal histor about clients diet, sleeping pattern bowel bladder pattern. Then regarding the occupational history to find type of work and environmental history to asses whether good and clean environment, clean and safe water adequate facilities for waste disposal adequate ventilation and lighting and then history abou which type of hospital they visit.

2.Objective data is data assessed by the health personal.The objective data collected during physical examination is by inspection, palpation,percussion, auscultation.General examintion and Systemwise examination.In general it includesassessing any change in appearence,and relevant anatomical changes,either change in skin colour or changes in physical appearence,posture sight,any abnormalities in hair, eyes, nose deviation,any wound or skin breakdown.then in system wise checking each system for any abnormalities. If any odema palpating to find pitting oedema or not and then auscultating breath sounds and assessing cardiovascular system for any abnormal sounds then assessing abdomen for distension and percussion done neurological examination done extimities and reflexes are asssessed.

3.EHR Means electronic health record in which details of patient and all clinical data relevant to patient is noted including the each days progress note of the client,about the clients problems reported day by day and also the medication given to the client is also properly noted in this EHR, where data is properly saved and update with each new encounter.