Recording health assessment NURSING FOUNDATION

1. A N I L K U M A R B R
L E C T U R E R
M S N
RECORDING OF HEALTH ASSESSMENT

2. Accurate recording is essential and should include
all information collected about the client health
status.
The assessment is documented in the patients
Medical or nursing records. Which may be on
paper or as part of the electronic medical record,
which can be accessed by all members of the health
care team or personal.

3. PURPOSE OF HEALTH ASSESSMENT RECORDING :
 The main purpose of health assessment record is to
provide a means of communication to facilitate the
safe care and treatment of the clients.
 The health assessment record may also be used for
communication with other health care personal
 Establish a basis for screening or validation proposed
diagnosis

4. Continue…
 Acts as a source of information to help diagnosis new
problems
 Offers a basis for determining the educational needs
of the client, family and significant others.
 Constitutes a permanent legal record of the care that
was or was not given to the client
 Helping the Medical or nursing research and
educational purposes.

5. GUIDELINES FOR RECORDING HEALTH ASSESSMENT :
 Record patients own words
 Avoid generalizations – be specific
 Privacy and confidentiality
 Use correct grammar and spelling
 Record complete information and details for all client
symptoms or experience