Chapter 29: Bedside Assessment and Electronic Health Recording

Question 1

Steps

Answer 1

1. Health History
2. General Appearance
3. Measurement
4. Neurologic System
5. Respiratory System
6. Cardiovascular System
7. Skin
8. Abdomen
9. Genitourinary
10. Activity

Question 2

SBAR - organizing assessment data for verbal communication

Answer 2

Situation
Background
Assessment
Recommendation

Question 3

SOAP - organizing assessment finding into written or charted information

Answer 3

Subjective
Objective
Assessment
Plan