Nursing Health Assessment

Ms. Anne Rose Calimlim, RN, LPT, MAN
PRMSU, Iba Main Campus - CON
SY: 2020-2021

This course will provide the nurse with the knowledge needed to provide a complete health
assessment for an adult patient. After successful completion of this course, you will be able to:
1. Ask appropriate questions when conducting a comprehensive health history to elicit data that
will be used to guide a physical examination.
2. List the components of the comprehensive physical examination and review of systems based
on red flags identified in the patient history.
3. Determine when to perform four different types of health assessments:
✓ Initial Comprehensive Assessment
✓ On-going or Partial Assessment
✓ Focused or Problem-Oriented Assessment
✓ Emergency Assessment

A. Overview of Nursing Process (ADPIE)
B. Health Assessment in Nursing Practices
C. Steps of Health Assessment
D. Guidelines for on an Effective Interview
and Health History
E. Guidelines for Documentation
F. Relevant Ethico-Legal Guidelines in
conducting Health Assessment
G. Health Care Team in Health Assessment

1. Health assessment refers to a systematic method of collecting and analyzing data
for the purpose of planning patient-centered care.
2. Safety considerations should be followed throughout any physical assessment.
3. Components of health assessment include conducting a health history,
performing a physical examination, and communicating and documenting the
findings.
4. The amount of information gained during a health assessment depends on
several factors, including the context of care, patient needs, and the health care
professional.
5. The data collected during the health assessment is organized and interpreted to
initiate or continue a plan of care.

Assessment:
Subjective Data:What your patient says
Objective Data:What you observe
Prioritization:
1.ABC
2. Maslow’s HON
3. Acute vs. Chronic
4. Actual vs. Potential
Diagnosis:
NANDA (problem, etiology, S/Sx)

Planning:
1. Long term
2. Short Term
Be SMART!
S- Specific
M- Measurable
A- Attainable
R- Realistic
T- Time bounded
Implementation:
1. Independent nursing intervention
2. Dependent
3. Inter-dependent
Evaluation:
1. Goals are met.
2. Goals are not met, in which case you have to go
back to planning.

Assessment Diagnosis Planning Intervention Evaluation
Subjective:
Objective:
Vital Signs
Use your Nanda
book for Nursing
Dx.
1.
2.
3.
1.
2.
3.
Goals met.
Goals Unmet.

A 56-year old female is being admitted to your ICU unit.The patient is coming to you
from the PACU.You received in report from the PACU nurse that the patient had
surgery on her right hip for a repair after a fall she sustained from her patio balcony.
You observe that the surgical dressing is clean, dry, and intact. An abductor pillow is
being used and pulses in feet are palpable.
The PACU nurse informs you that the patient has become unstable and need close
monitoring that is available in the ICU.The PACU nurse states that the patient has
been unable to regulate her own body temperature and her current temperature in
94.4 degrees. A bear hugger blanket is being used.The patient is extremely drowsy
and confused and the nurse has been unsuccessful in getting the patient to fully
wake up from the anesthesia.
Pt HR is 50-55 bpm and BP 80/42. Pt is currently on a Dopamine gtts at 30 mcg/min.
RR 12 and O2 Sat 95% on a 50% ventimask.

Assessment: Subjective:
The PACU nurse informs you that the patient has become unstable and
need close monitoring that is available in the ICU. PACU nurse states that
the patient has been unable to regulate her own body temperature.A bear
hugger blanket is being used.The patient is extremely drowsy and
confused and the nurse has been unsuccessful in getting the patient to fully
wake up from the anesthesia.
Objective:
A 56-year old female is being admitted to your ICU unit. Surgical dressing
is clean, dry, and intact. An abductor pillow is being used and pulses in feet
are palpable.
HR is 50-55 bpm
BP 80/42.
RR 12
Temp: 94.4 Farenheit
O2 Sat 95% on a 50% ventimask.
IV with Dopamine inserted at 30 mcg/min.
Diagnosis: Hypothermia related to surgery as evidenced by reduction of body
temperature of 94.4 degrees, mental confusion, drowsiness, and decreased
pulse and respirations.

Planning: 1. Pt’s temperature will between 98.2-98.6 degrees within 12 hours from
arrival to ICU unit.
2. Pt’s HR will be 60-100 bpm and BP SBP 100-130 within 6 hours from
3. Pt will be able to verbalize self, place, and time within 12 hours from
Intervention: 1.The nurse will assess every hour patient’s temperature and report any
temperature less than 95 degrees to the doctor for further orders.
2.The nurse will assess HR and BP every 15 minutes.
3.The nurse will administer warming intravenous fluids per md order.
4.The nurse will assess patient’s room temperature every 2 hours and will
keep patient’s room temperature between 70-74 degrees.
5.The nurse will use the bear hugger warming blanket system per hospital
protocol and md order.
Evaluation: Goals met.

▪ The first step in determining the health status
of the client.
▪ The entire plan of care is based on the data
collected during this phase.
▪ Ensure that your information is correct,
complete and organized in a way that helps
you begin in getting a sense of patterns of
health or illness.
▪ Inspection, palpation, percussion and
auscultation are techniques used to gather
information. Clinical judgment should be
used to decide on the extent
of assessment required.

▪ An initial comprehensive assessment describes in detail the client's
medical, physical and psychosocial condition and needs.
▪ It identifies service needs being addressed and by whom; services
that have not been provided; barriers to service access; and services
not adequately coordinated.
▪ Gives you insight into a patient's physical status through observation,
the measurement of vital signs and self-reported symptoms. It
includes a medical history, a general survey and a complete physical
examination.

▪ Consists of data collection that occurs after the comprehensive
database is established.
▪ Consists of mini-overview of the client’s body systems and holistic
health patterns as a follow-up on his health status.
▪ Brief reassessment of the client's normal body system or wholistic
health patterns performed to detect new problems.

▪ A problem-focused assessment is an assessment based on certain
care goals.
▪ Consists of a thorough assessment of a particular health problem and
does not cover areas not related to the problem.
▪ These assessments are generally focused on a specific body system
such as respiratory or cardiac.

▪ A very rapid assessment performed in a life-threatening situation.
▪ Rapid assessment done during any physiologic crisis of the client to
identify life threating problems.

▪ You are assessing a patient at
the beginning of your shift.
Which assessment would be the
most appropriate?
▪ You come back from a break to
find your patient complaining
that she feels short of
breath.Which assessment
would be the most appropriate?
TEST YOURSELF

TEST YOURSELF
Which question is the best to
ask a client when they first
arrive at the hospital?
A. Do you need to see a
doctor?
B. Why did you come to the
hospital?
C. Is there something wrong
with you today?
D. Tell me about what brought
you to the hospital.

▪ Inspection is the most frequently
used assessment technique.
▪ Inspection can be an important
technique as it leads to further
investigation of findings.
• Deliberate, purposeful, and
systematic visual examination
• Moisture, color, texture of body
surfaces
• Shape, position, size, symmetry
of body
Inspection is a critical observation that should always occur first during an assessment (Jarvis, 2016).

▪ Auscultation usually performed following
inspection, especially with abdominal
assessment.
▪ When auscultating, ensure the exam
room is quiet and auscultate over bare
skin, listening to one sound at a time.
▪ The bell or diaphragm of your
stethoscope should be placed on your
patient’s skin firmly enough to leave a
slight ring on the skin when removed.
▪ Direct: use of unaided ear
▪ Indirect: use of stethoscope to determine
pitch, intensity, duration, and quality

▪ Palpation requires you to touch your patient
with different parts of your hand using
different strength pressures.
▪ During light palpation, you press the skin
about ½ inch to ¾ inch with the pads of
your fingers. Light palpation allows you to
assess for texture, tenderness, temperature,
moisture, pulsations, and masses.
▪ When using deep palpation, use your finger
pads and compress the skin approximately
1½ inches to 2 inches. Deep palpation is
performed to assess for masses and internal
organs.

Percussion
▪ Striking body surface to
elicit sounds or vibrations
▪ Determines size, shape,
borders of internal organs
▪ Direct: Striking body
directly
▪ Indirect: Striking an
object held against the
body (pleximeter, plexor)

1. Flatness: normally heard over solid areas such as bones.
2. Dullness: suggests fluid or underlying organs like the
liver and spleen. Dullness replaces resonance when fluid
or solid tissue replaces air-containing lung tissues, such
as occurs with pneumonia, pleural effusions, or tumors.
3. Resonance: sounds are low pitched, hollow sounds heard
over normal lung tissue.
4. Hyperresonance: Often of lower pitch than resonance.
Occurs in the chest as a result of over-inflation of the
lungs as in emphysema or pneumothorax and in the
abdomen over distended bowel.
5. Tympany: a high-pitched musical sound that indicates a
hollow space filled by air or gas in the stomach or
intestine.

1. COLLECTION
OF SUBJECTIVE
DATA
1. Biographic Data
2. Reasons for seeking
Health Care
3. Chief complaint
4. History of present
illness, past health
history, family health
history, current
medications and
lifestyle.

Health History Checklist
Steps Additional Information
Determine the following:
1. Biographical data
•Name
•Age
•Occupation (past or present)
•Marital status/living arrangement
2. Reason for seeking care and
history of present health concern
•Chief complaint
•Onset of present health concern
•Duration
•Signs, symptoms,and related problems
•Medications or treatments used (ask how effective they were)
•What aggravates this health concern
•What alleviates the symptoms
•What caused the health concern to occur
•Related health concerns
•How the concern has affected life and daily activities
•Previous history and episodes of this condition

3. Past health history
•Allergies (reaction)
•Serious or chronic illness
•Recent hospitalizations
•Recent surgical procedures
•Emotional or psychiatric problems (if pertinent)
•Current medications: prescriptions, over the counter, herbal
remedies
•Drug/alcohol consumption
4. Family history
•Pertinent health status of family members
•Pertinent family history of heart disease, lung disease, cancer,
hypertension, diabetes, tuberculosis, arthritis, neurological
disease, obesity, mental illness, genetic disorders

5. Functional assessment (including
activities of daily living)
•Activity/exercise, leisure and recreational activities (assess for
falls risk)
•Sleep/rest
•Nutrition/elimination
•Interpersonal relationships/resources
•Coping and stress management
•Occupational/environmental hazards
6. Developmental tasks •Current significant physical and psychosocial changes/issues
7. Cultural assessment
•Cultural/health-related beliefs and practices
•Nutritional considerations related to culture
•Social and community considerations
•Religious affiliation/spiritual beliefs and/or practices
•Language/communication

Client Assessment Sample Responses
Presenting to a clinic or a
hospital emergency or urgent
care (first point of contact).
Tell me about what brought
you here today.
Probes
•Tell me more.
•How is that affecting you?
•“I have a rash”
•“I have been feeling quite
depressed lately”
•“I’m having pain”
Already admitted, and you are
starting your shift.
Tell me about your main
health concerns today.
•“When will I be
discharged?”
•“I’m really hungry, can I eat
something today?”
It is important to avoid asking questions that begin with “why,” which may suggest to the client that they
did something wrong or that they are to blame for what is happening to them.

Primary source: data
gathered from the client
using interview and physical
examination.
Secondary source: data
gathered from client’s family
members, significant others,
client’s medical chart, or
other member’s of health
team.

2. COLLECTION
OF OBJECTIVE
DATA
a. Physical Examination
b. Diagnostic test and
procedures
c. Other sources e.g. client
chart

▪ An interview is a planned communication.
▪ The nurse interviews the patient to obtain a
nursing history.
▪ Strong interviewing skills are needed to
establish a successful working partnership
with the patient, to communicate care and
concern for the patient, and to obtain the
necessary patient data.
▪ The interview can be understood in terms of
its four phases, which include the
preparatory phase, introduction, working
phase, and termination.

▪ Prepare to meet the patient by reading current and past records and reports, when
available.
▪ During this phase, it is important not to let one's stereotypes and prejudices affect
the nurse–patient relationship. Be aware of your own prejudices and deal with them
constructively.
▪ Learn to approach patients with open minds and to be sensitive to the human
needs that underlie diverse behaviors.

▪ Introduce yourself to the client.
▪ Explain the purpose of the interview, discuss the types of questions that will be
asked, explain the reason for taking notes, and assure the client that conﬁdential
information will remain conﬁdential.
▪ Make sure that the client is comfortable (physically and emotionally)and has
privacy.
▪ Develop trust and rapport at this point in the interview.This can begin by
conveying a sense of priority and interest in the client. Developing rapport
depends heavily on verbal and nonverbal communication on the part of the nurse.

▪ During this phase,YOU elicit the client’s comments about major biographic data,
reasons for seeking care, history of present health concern, past health history,
family history, review of body systems for current health problems, lifestyle and
health practices, and developmental level.
▪ YOU listen, observe for cues, and use critical thinking skills to interpret and
validate information received from the client.
▪ YOU and the client collaborate to identify the client’s problems and goals.
▪ The facilitating approach may be free-ﬂowing or more structured with speciﬁc
questions, depending on the time available and the type of data needed.

▪ During this phase,YOU will summarize the information obtained during the
working phase and validate problems and goals with the client.
▪ YOU also identify and discuss possible plans to resolve the problem (nursing
diagnoses and collaborative problems) with the client.
▪ Finally,YOU makes sure to ask if the client has anymore concerns and if there are
any further questions they might like to ask.

TYPES OF
COMMUNICATION
The client interview involves two
types of communication:
▪ Verbal Communication is essential
to a client interview. The goal of the
interview process is to elicit as
much data about the client’s health
status as possible.
▪ Nonverbal Communication is as
important as verbal communication.
Your appearance, demeanor,
posture, facial expressions, and
attitude strongly inﬂuence how the
client perceives the questions you
ask. Never overlook this type of
communication or take it for
granted..

OPEN-ENDED QUESTIONS
▪ Used to elicit the client’s feelings and perceptions.
▪ They typically begin with the words “how” or “what.” An example of
this type of question is “How have you been feeling lately?”
▪ These types of questions are important because they require more
than a one-word response from the client and, therefore, encourage
description.
▪ Asking open-ended questions may help to reveal signiﬁcant data
about the client’s health status.

CLOSED-ENDED QUESTIONS
▪ Use closed-ended questions to obtain facts and to focus on speciﬁc
information.
▪ The client can respond with one or two words.
▪ The questions typically begin with the words “when” or “did.” An
example of this type of question is “When did your headache start?”
▪ Closed-ended questions can also be used to clarify or obtain more
accurate information about issues disclosed in response to open-
ended questions.

LAUNDRY LIST
▪ Another way to ask questions is to provide the client with a choice of
words to choose from in describing symptoms, conditions, or
feelings.
▪ This laundry list approach helps you to obtain speciﬁc answers and
reduces the likelihood of the client’s perceiving or providing an
expected answer.

REPHRASING
▪ Rephrasing information the client has provided is an effective way to
communicate during the interview.
▪ This technique helps you to clarify information the client has stated; it
also enables you and the client to reﬂect on what was said.
▪ For example, your client, Mr. G., tells you that he has been really tired
and nauseated for 2 months and that he is scared because he fears
that he has some horrible disease.You might rephrase the
information by saying,“You are thinking that you have a serious
illness?”

WELL-PLACED PHRASES
▪ Client verbalization can be encouraged by well-placed phrases from
the nurse.
▪ If the client is in the middle of explaining a symptom or feeling and
believes that you are not paying attention, you may fail to get all the
necessary information.
▪ Listen closely to the client during his or her description and use
phrases such as “um-hum,”“yes,” or “I agree” to encourage the client
to continue.

INFERRING
▪ Inferring information from what the client tells you and what you observe in the
client’s behavior may elicit more data or verify existing data.
▪ Be careful not to lead the client to answers that are not true.
▪ An example of inferring information follows:Your client, Mrs. J., tells you that she
has bad pain.You ask where the pain is, and she says,“My stomach.”You notice the
client has a hand on the right side of her lower abdomen and seems to favor her
entire right side.You say,“It seems you have more difﬁculty with the right side of
your stomach” (use the word “stomach” because that is the term the client used to
describe the abdomen).This technique, if used properly, helps to elicit the most
accurate data possible from the client.

PROVIDING INFORMATION
▪ Another important thing to consider throughout the interview is to
provide the client with information as questions and concerns arise.
▪ Make sure you answer every question as well as you can. If you do not
know the answer, explain that you will ﬁnd out for the client.
▪ The more clients know about their own health, the more likely they
are to become equal participants in caring for their health.

APPEARANCE
▪ Ensure that your appearance is professional.
▪ The client expects to see a health professional;
therefore, you should look the part.
▪ Wear comfortable, neat clothes and a laboratory
coat or a uniform.
▪ Be sure your name tag, including credentials, is
clearly visible.
▪ Your hair should be neat and not in any extreme
style; some nurses like to wear long hair pulled
back.
▪ Fingernails should be short and neat.
▪ Jewelry should be minimal.

DEMEANOR
▪ Your demeanor should be professional.
▪ When you enter a room to interview a client, display poise.
▪ Focus on the client and the upcoming interview and assessment.
▪ Do not enter the room laughing loudly, yelling to a coworker, or muttering under
your breath.This appears unprofessional to the client and will have an effect on the
entire interview process.
▪ Greet the client calmly and focus your full attention on them.

FACIAL EXPRESSION
▪ Facial expressions are often an overlooked aspect of communication.
▪ Facial expression often shows what you are truly thinking (regardless of what you
are saying), keep a close check on your facial expression.
▪ No matter what you think about a client or what kind of day you are having, keep
your expression neutral and friendly.
▪ Portraying a neutral expression does not mean that your face lacks expression. It
means using the right expression at the right time.

ATTITUDE
▪ One of the most important nonverbal skills to develop as a health care professional is a
nonjudgmental attitude.
▪ All clients should be accepted, regardless of beliefs, ethnicity, lifestyle, and health care practices.
▪ Do not act superior to the client or appear shocked, disgusted, or surprised at what you are told.
These attitudes will cause the client to feel uncomfortable opening up to you and important data
concerning his or her health status could be withheld.
▪ Being nonjudgmental involves not “preaching” to the client or imposing your own sense of ethics
or morality on him.
▪ Focus on health care and how you can best help the client to achieve the highest possible level of
health.

SILENCE
▪ Another nonverbal technique to use during the interview process is silence.
▪ Periods of silence allow you and the client to reﬂect and organize thoughts, which
facilitates more accurate reporting and data collection.

LISTENING
▪ Listening is the most important skill to learn and develop fully in order to collect
complete and valid data from your client.
▪ Maintain good eye contact, smile or display an open, appropriate facial expression,
maintain an open body position (open arms and hands and lean forward).
▪ Avoid preconceived ideas or biases about your client.
▪ Keep an open mind.
▪ Avoid crossing your arms, sitting back, tilting your head away from the client,
thinking about other things, or looking blank or inattentive.

Three variations in communication must be considered
as you interview clients:
1. Gerontologic (age)
2. Cultural
3. Emotional
These variations affect the nonverbal and verbal
techniques you use during the interview.
For example:You are interviewing an 82-year-old
woman and you ask her to describe how she has been
feeling. She does not answer you and she looks
confused.This older client may have some hearing loss.
In such a case, you may need to modify the verbal
technique of asking open-ended questions.

▪ Age affects and commonly slows all
body systems to varying degrees.
▪ However, normal aspects of aging
do not necessarily equate with a
health problem.
▪ It is important not to approach an
interview with an elderly client
assuming that there is a health
problem.
▪ Older clients have the potential to
be as healthy as younger clients.

▪ When interviewing an elderly
client, you must ﬁrst assess
hearing acuity.
▪ If you detect hearing loss, speak
slowly.
▪ Face the client at all times during
the interview, and position
yourself so that you are speaking
on the side of the client that has
the ear with better acuity.
▪ Do not yell at the client.

▪ Older clients may have more health
concerns and may seek health care
more often.
▪ Establishing and maintaining trust,
privacy, and partnership with the older
client is particularly important.
▪ It is not unusual for elderly clients to be
taken for granted and their health
complaints ignored, causing them to
become fearful of complaining.

▪ Speak clearly and use
straightforward language.
▪ Ask questions in simple terms.
▪ Avoid medical jargon and modern
slang.
▪ Do not talk down to the client. Being
older physically does not mean the
client is slower mentally.
▪ If the older client is mentally
confused or forgetful, it is important
to have a signiﬁcant other present
during the interview to provide or
clarify the data.
▪ Show respect.

▪ Ethnic/cultural variations in communication and self-
disclosure styles may signiﬁcantly affect the
information obtained (Andrews & Boyle, 1999; Giger &
Davidhizar, 1995; Luckmann, 2000).
▪ Be aware of possible variations in the communication
styles of yourself and the client.
▪ If misunderstanding or difficulty in communicating is
evident, seek help from an interpreter.This person
should be familiar not only with the client’s language,
culture, and related health care practices but also with
the health care setting and system of the dominant
culture.
▪ Keep in mind that communication through use of
pictures may be helpful when working with some
clients.

Frequently noted variations in communication styles
include:
▪ Reluctance to reveal personal information to
strangers for various culturally-based reasons.
▪ Variation in willingness to openly express emotional
distress or pain .
▪ Variation in ability to receive information (listen).

▪ Variation in meaning conveyed by language.
▪ For example, a client who does not speak
the predominant language may not know
what a certain medical term or phrase
means and, therefore, will not know how to
answer your question.
▪ Use of slang with non-native speakers is
discouraged.
▪ Keep in mind that it is hard enough to learn
proper language, let alone the idiom
vernacular.The non-native speaker will
likely have no idea what you are trying to
convey.

▪ Variation in disease/illness perception: Culture
speciﬁc syndromes or disorders are accepted by
some groups (e.g., in Latin America, susto is an
illness caused by a sudden shock or fright).
▪ Variation in past, present, or future time orientation
(e.g., the dominant U.S. culture is future oriented;
other cultures may focus more on the past or
present).
▪ Variation in the family’s role in the decision-making
process: A person other than the client or the client’s
parent may be the major decision maker about
appointments, treatments, or follow-up care for the
client.

▪ Variation in use and meaning of
nonverbal communication: eye contact,
stance, gestures, demeanor.
▪ For example, direct eye contact may be
perceived as rude, aggressive, or
immodest by some cultures but lack of
eye contact may be perceived as
evasive, insecure, or inattentive by
other cultures.
▪ A slightly bowed stance may indicate
respect in some groups; size of
personal space affects one’s
comfortable interpersonal distance;
touch may be perceived as comforting
or threatening.

Not every client you encounter will be calm, friendly, and
eager to participate in the interview process. Clients’
emotions vary for a number of reasons.
They may be scared or anxious about their health or
about disclosing personal information.
They may be angry that they are sick or about having to
have an examination.
They may be depressed about their health or other life
events.
They may have an ulterior motive for having an
assessment performed.
Clients may also have some sensitive issues with which
they are grappling and may turn to you for help.

Anxious Client
▪ Provide the client with simple, organized information in a structured format.
▪ Explain who you are and your role and purpose.
▪ Ask simple, concise questions.
▪ Avoid becoming anxious like the client.
▪ Do not hurry and decrease any external stimuli.

Angry Client
▪ Approach this client in a calm, reassuring, in-control manner.
▪ Allow him to ventilate feelings. However, if the client is out of control, do not argue
with or touch the client.
▪ Obtain help from other health care professionals as needed.
▪ Avoid arguing and facilitate personal space so the client does not feel threatened
or cornered.

Depressed Client
▪ Express interest in and understanding of the client and respond in a neutral
manner.
▪ Do not try to communicate in an upbeat, encouraging manner.
▪ This will not help the depressed client.

Manipulative Client
▪ Provide structure and set limits.
▪ Differentiate between manipulation and a reasonable request.
▪ If you are not sure whether you are being manipulated, obtain an objective opinion
from other nursing colleagues.

Seductive Client
▪ Set ﬁrm limits on overt sexual client behavior and avoid responding to subtle
seductive behaviors.
▪ Encourage client to use more appropriate methods of coping in relating to others.

When Discussing Sensitive Issues (for example, Sexuality, Dying, Spirituality)
▪ First be aware of your own thoughts and feelings regarding dying, spirituality, and
sexuality; then recognize that these factors may affect the client’s health and may
need to be discussed with someone.
▪ Ask simple questions in a nonjudgmental manner.
▪ Allow time for ventilation of client’s feelings as needed.
▪ If you do not feel comfortable or competent discussing personal, sensitive topics,
you may make referrals as appropriate, for example, to a counselor or priest for
spiritual concerns or other specialists as needed.

▪ Good record keeping is an important aspect of a health care
professional’s role, and it is a fundamental part of nursing.
▪ Record keeping is a tool for professional practice and one that should
help the care process. It is not separate and not an optional extra to
be fitted in if circumstances allow.
▪ A record should be made as soon as possible after the patient is seen
or the procedure is complete.

1. Record keeping makes the
continuity of care easier.
2. Promotes better communication
and dissemination of information
between members of the multi-
professional team.
3. Helps to identify risks and enables
the early detection of
complications.
4. Supports patient care and patient-
centered communication.
5. Supports effective clinical
judgement.
6. Supports delivery of services.
7. Helps improve accountability.
8. Shows how decisions were made
relating to the patient’s care.
9. Helps to address complaints or
legal processes.

1. Hand-written records
2. Computer-based systems (electronic)
3. Some organizations or employers will use a combination of both.
You’ll be expected to be able to comply with whatever requirements your
employer or organization sets for record-keeping.That means you’ll need to:
▪ Ensure that you are up to date on the information systems and tools in your
workplace including their security, confidentiality and appropriate usage;
▪ Protect any passwords or details given to you to enable your access to any
systems;
▪ Make sure written records are not left in public places where unauthorized
people might see them (including any electronic systems or displays);
▪ Ensure that an entry is made in the patient’s medical record whenever a health
professional sees a patient.

▪ Admission sheet
▪ Informed consent forms
▪ Vital signs observation
charts
▪ Laboratory orders and
reports
▪ Medication charts
▪ Doctor’s Notes
▪ Nurse’s Notes/progress
notes
▪ Discharge and transfer
checklists

The patient’s records should:
1. Be factual, consistent and accurate.
2. Be updated as soon as possible after
any recordable event.
3. Provide current information on the
care and condition of the patient.
4. Be consecutive and accurately dated,
timed and all entries signed
(including any alterations).
5. All original entries should be
legible. Draw a clear line through
any changes and sign and date.
6. Not include abbreviations or slang as
not all workplaces or organizations
will use the same terminology.
7. Records must be stored securely.
8. Avoid meaningless phrases,
speculation and offensive subjective
statements/insulting or derogatory
language.
9. Identify the patient by recording
patient’s name, date of birth and
hospital number on each page of the
record (three approved identifiers)
or follow your local policies on how
to identify patient’s records.

1. Right to Appropriate Medical Care and Humane Treatment
▪ Every person has a right to health and medical care corresponding to his state of health, without
any discrimination.
▪ Right to appropriate health and medical care of good quality.
▪ Patient’s human dignity, convictions, integrity, individual needs and culture shall be respected.
▪ If the patient must wait for care, he shall be informed of the reason for the delay.
▪ If any person cannot immediately be given treatment that is medically necessary, the patient has
the right to be referred or sent for treatment elsewhere, where the appropriate care can be
provided.
▪ Patients in emergency shall be extended immediate medical care and treatment without any form
of advance payment for treatment.

2. Right to Informed Consent
The patient has a right to a clear, truthful and substantial explanation, in a manner and
language understandable to the patient of all proposed procedures, whether:
✓diagnostic,
✓preventive,
✓curative,
✓rehabilitative or
✓therapeutic,
Wherein the person who will perform the said procedure shall provide his name and
credentials to the patient, possibilities of any risk of mortality or serious side effects,
problems related to recuperation, and probability of success and reasonable risks
involved.

INFORMED
CONSENT
The patient will not be subjected to any procedure without his
written informed consent, except in the following cases:
a) In emergency cases, when the patient is at imminent risk of
physical injury and when there is a possibility of death if
treatment is withheld or postponed. In such cases, the physician
can perform any diagnostic or treatment procedure as good
practice of medicine without such consent.
b) When the health of the population is dependent on the
adoption of a mass health program to control epidemic.
c) When the law makes it compulsory for everyone to submit a
procedure.
d) When the patient is either a minor, or legally incompetent, in
which case, a third party consent is required;
e) When disclosure of material information to patient will
jeopardize the success of treatment, in which case, third party
disclosure and consent shall be in order;
f) When the patient waives his right in writing.
Calimlim, A. 2020-2021. Health Assessment

➢Informed consent shall be obtained from a
patient concerned if he is of legal age and of
sound mind.
➢In case the patient is incapable of giving
consent and a third party consent is required,
the following persons, in the order of
priority stated hereunder, may give consent:
i. spouse;
ii. son or daughter of legal age;
iii. either parent;
iv. brother or sister of legal age, or
v. guardian

▪ If a patient is a minor, consent shall
be obtained from his parents or
legal guardian.
▪ If next of kin, parents or legal
guardians refuse to give consent
to a medical or surgical procedure
necessary to save the life or limb
of a minor or a patient is incapable
of giving consent, then the
physician or any person interested
in the welfare of the patient may
petition the case in a lawful court.
In which case, the court may issue
an order giving consent.

3. Right to Privacy and Confidentiality
▪ The privacy of the patients must be assured at all stages of his
treatment.
▪ The patient has the right to be free from unwarranted public
exposure, except in the following cases:
a) When his mental or physical condition is in controversy and the appropriate
court, in its discretion, order him to submit to a physical or mental examination
by a physician;
b)When the public health and safety so demand; and
c) when the patient waives this right in writing.

RIGHT TO PRIVACY
AND
CONFIDENTIALITY
➢The patient has the right to demand that all
information, communication and records pertaining
to his care be treated as confidential.
➢Any health care provider or practitioner involved in
the treatment of a patient and all those who have
legitimate access to the patient's record is not
authorized to divulge any information to a third
party who has no concern with the care and
welfare of the patient without his consent, except:
a) When it is in the interest of justice and upon the
order of a competent court.
b) When the patients waives in writing the
confidential nature of such information.
c) When it is needed for continued medical
treatment or advancement of medical science
subject to de-identification of patient and shared
medical confidentiality for those who have access
to the information.

RIGHT TO PRIVACY
AND
CONFIDENTIALITY
➢Informing the spouse or the
family to the first degree of the
patient's medical condition may
be allowed; provided that the
patient of legal age shall have the
right to choose on whom to
inform.
➢In case the patient is not of legal
age or is mentally incapacitated,
such information shall be given to
the parents, legal guardian or his
next of kin.

4. Right to Information
In the course of the patient’s treatment and hospital care, the patient or their legal guardian has a right
to be informed of the following:
a. Result of the evaluation of the nature and extent of his/her disease.
b. Any other additional or further contemplated medical treatment on surgical procedures.
c. Any other additional medicines to be administered and their generic counterpart including the
possible complications.
d. Statistics or studies regarding their illness.
e. Any change in the plan of care before the change is made.
f. The person's participation in the plan of care and necessary changes before its implementation.
g. The extent to which payment maybe expected from Philhealth or any payor and any charges for
which the patient maybe liable.
h. The disciplines of health care practitioners who will furnish the care and the frequency of services
that are proposed to be furnished.

RIGHT
TO INFORMATION
The patient or legal guardian has
the right to examine and be given an
itemized bill of the hospital and medical
services rendered in the facility or by
their physician and other health care
providers, regardless of the manner and
source of payment. Patient is entitled to
a thorough explanation of such bill.
The patient or legal guardian has
the right to be informed by the
physician of their continuing health care
requirements following discharge,
including instructions about home
medications, diet, physical activity and
all other pertinent information to
promote health and well-being.

RIGHT
TO INFORMATION
➢At the end of his/her confinement, the
patient is entitled to a brief, written
summary of the course of their illness
which shall include at least the history,
physical examination, diagnosis,
medications, surgical procedure,
laboratory procedures, and the plan of
further treatment which shall be
provided by the attending physician.
➢With the presence of their attending
physician or hospital’s representative,
the patient is also entitled to the
explanation of, and to view the contents
of their medical record while confined.
➢The patient shall likewise be entitled to
a medical certificate, free of charge, with
respect to their previous confinement.

5.The Right to Choose Health Care Provider and Facility
➢The patient is free to choose the health care provider to serve him as
well as the facility except when he is under the care of a service
facility or when public health and safety so demands or when the
patient expressly waives this right in writing.
➢The patient has the right to discuss his condition with a consultant
specialist, at the patient's request and expense. He also has
the right to seek for a second opinion and subsequent opinions, if
appropriate, from another health care provider.

6. Right to Self-Determination
▪ The patient has the right to avail themself of any recommended
diagnostic and treatment procedures.
▪ Any person of legal age and of sound mind may make an advance
written directive for physicians to administer terminal care when they
suffer from the terminal phase of a terminal illness, provided that:
a) He is informed of the medical consequences of his choice.
b) He releases those involved in his care from any obligation
relative to the consequences of his decision.
c) His decision will not prejudice public health and safety.

7. Right to Religious Belief
The patient has the right to refuse medical treatment or procedures
which may be contrary to his religious beliefs, subject to the
limitations described in the preceding subsection, provided:
(a) That such a right shall not be imposed by parents upon their
children who have not reached the legal age in a life threatening
situation as determined by the attending physician or the medical
director of the facility.

8. Right to Medical Records
➢The patient is entitled to a summary of his medical history and
condition.
➢He has the right to view the contents of his medical records, except
psychiatric notes and other incriminatory information obtained about
third parties, with the attending physician explaining contents
thereof.
➢At his expense and upon discharge of the patient, they may obtain
from the health care institution a reproduction of the same record
whether or not he has fully settled his financial obligation with the
physician or institution concerned.

RIGHT TO
MEDICAL
RECORDS
➢The health care institution shall
safeguard the confidentiality of the
medical records and to likewise ensure
the integrity and authenticity of the
medical records and shall keep the
same within a reasonable time as may
be determined by the Department of
Health.
➢The health care institution shall issue a
medical certificate to the patient upon
request. Any other document that the
patient may require for insurance claims
shall also be made available to him
within forty-five (45) days from request.

9. Right to Leave
The patient has the right to leave hospital or any other health care
institution regardless of his physical condition, provided that:
a) They are informed of the medical consequences of their decision.
b) They release those involved in their care from any obligation
relative to the consequences of their decision.
c) Their decision will not prejudice public health and safety.

10. Right to Refuse Participation In Medical Research
The patient has the right to be advised if the health care provider plans to involve him
in medical research, including but not limited to human experimentation which may be
performed only with the written informed consent of the patient:
a) Provided that, an institutional review board or ethical review board in accordance
with the guidelines set in the Declaration of Helsinki be established for research
involving human experimentation.
b) Provided further, that the Department of Health shall safeguard the continuing
training and education of future health care provider/practitioner to ensure the
development of the health care delivery in the country.
c) Provided furthermore, that the patient involved in the human experimentation shall
be made aware of the provisions of the Declaration of Helsinki and its respective
guidelines.

11. Right to Correspondence and to ReceiveVisitors
➢The patient has the right to communicate with relatives and
other persons and to receive visitors subject to reasonable limits
prescribed by the rules and regulations of the health care institution.

12. Right to Express Grievances
➢The patient has the right to express complaints and grievances
about the care and services received without fear of discrimination
or reprisal and to know about the disposition of such complaints.
➢Such a system shall afford all parties concerned with the opportunity
to settle amicably all grievances.

13. Right to be Informed of His Rights and Obligations as a Patient.
➢Every person has the right to be informed of his rights and obligations as a patient.
➢The Department of Health, in coordination with heath care providers, professional and
civic groups, the media, health insurance corporations, people's organizations, local
government organizations, shall launch and sustain a nationwide information
and education campaign to make known to people their rights as patients, as
declared in this Act.
➢Such rights and obligations of patients shall be posted in a bulletin board
conspicuously placed in a health care institution.
➢It shall be the duty of health care institutions to inform of their rights as well as of the
institution's rules and regulations that apply to the conduct of the patient while in the
care of such institution.

➢An interdisciplinary approach relies
on health professionals from different disciplines,
along with the patient, working collaboratively as
a team.The most effective teams share
responsibilities and promote role
interdependence while respecting individual
members' experience and autonomy.
➢An effective team is a one where
the team members, including the patients,
communicate with each other, as well as merging
their observations, expertise and decision-
making responsibilities to optimize patients' care.

Doctors or physicians, are key members of the healthcare team.They have years of
education and training.They may be primary care doctors or specialists.
▪ Primary care doctors
When patients need medical care, they first go to primary care doctors. Primary
care doctors focus on preventive healthcare. This includes regular check-ups,
disease screening tests, immunizations and health counseling. Primary care
doctors may be family practitioners or internal medicine. Pediatricians also
provide primary care for babies, children and teenagers. Primary care
pediatricians treat day-to-day illnesses and provide preventive care such as minor
injuries, viral infections, immunizations and check-ups.
▪ Specialists
Specialists diagnose and treat conditions that require a special area of knowledge.
Patients may see a specialist to diagnose or treat a specific short-term condition or,
if they have a chronic disease, they may see a specialist on an ongoing basis.
Examples of specialties includes: endocrinology, dermatology and obstetrics.

Nurses work closely with patients. A nurse’s job duties depend on their education,
area of specialty and work setting.Types of nurses include:
▪ Registered Nurses (RN’s) RNs are often the first healthcare professional a patient
comes into contact with regarding medication, treatment plans, and other
provisions vital to the individual’s health or recovery.
▪ Clinical Nurse Specialist (CNS) A CNS is a highly trained and rigorously
educated subdivision of nurse and are deeply specialized in a particular area of
medicine or treatment. CNSs are implemented as experts in a given area of
practice, and the range of areas that they can specialize in is very wide: there are
CNSs for locations like emergency rooms and intensive care units, for specific
diseases like cancer and diabetes, for particular types of ailments like wounds or
mental trauma, and many more.

Pharmacists
▪ Pharmacists give patients medicines that are prescribed, or recommended, by a
doctor.They tell patients how to use medicines and answer questions about side
effects. Sometimes pharmacists help doctors choose which medicines to give
patients and let doctors know if combinations of medicines may interact and harm
patients.
Dentists
▪ Dentists diagnose and treat problems with teeth and mouth, along with giving
advice and administering care to help prevent future problems.They teach patients
about brushing, flossing, fluoride, and other aspects of dental care.They treat tooth
decay, fill cavities and replace missing teeth.

Technologists and Technicians have a technical role in diagnosing or treating
disease.They work in a variety of settings. Examples of technologists and
technicians include:
▪ Laboratory Technologists help providers diagnose and treat disease by
analyzing body fluids and cells.They look for bacteria or parasites, analyze
chemicals, match blood for transfusions, or test for drug levels in the blood to see
how a patient is responding to treatment.
▪ Radiology Technologists, also called radiographers, help providers diagnose and
treat disease by taking x-rays. For some procedure's technologists make a solution
that patients drink to help soft body tissues can be seen. Radiology technologists
can specialize in computed tomography (CT scans), Magnetic Resonance Imaging
(MRI’s) or mammography.

▪ Therapists and Rehabilitation Specialists help people recover from physical
changes caused by a medical condition, chronic disease or injury.
▪ Physical Therapists (PT's) help patients when they have an injury, disability or
medical condition that limits their ability to move or function. Physical therapists
test a patient's strength and ability to move and create a treatment plan.The goal of
treatment is to improve mobility, reduce pain, restore function or prevent further
disability. PT's may treat patients who have had an amputation, stroke, injury or
chronic disease.
▪ Respiratory Therapists treat and care for patients with breathing problems.They
work with all types of patients including premature babies, older people with lung
disease, or patients with asthma or emphysema.

▪ When patients visits a healthcare provider, the visit involves many more people than
just the doctor. Here's an example of healthcare professionals involved in a patient visit:
▪ Members of the administrative staff finds the medical record, greets the patient and
verify insurance information.
▪ A nurse or assistant records the patient's weight and vital signs, escorts the patient to an
exam room and records the reason for the visit.
▪ The doctor, or nurse then examines and talks with the patient to develop a diagnosis
and plan of care.
▪ If a lab or radiology test is ordered, a technician performs the test.They will perform
the analysis and write up the test results.
▪ If treatment, such as medication is prescribed, a pharmacist dispenses the medication.
▪ Medical billing experts then bill the patient's insurance for the office visit and either the
test or the medication.

1. Caregiver. As a caregiver, nurses are expected to assist the
client’s physical, psychological, developmental, cultural
and spiritual needs. It involves a full care to a completely
dependent client, partial care for the partially dependent
client and supportive-educative care, in order to attain the highest
possible level of health and wellness.
2. Communicator. Communication is very important in nursing roles.
It is vital to establish nurse-client relationship. Nurses who
communicate effectively get better information about the client’s
problem either from the client itself or from his family.

3. Teacher. Being a teacher is an important role for a nurse.It is their
duty to give health education to the clients, families and
community.
4. Client Advocate. An advocator is the one who expresses and
defends the cause of another or acts as representative. Some
people who are ill maybe too weak to do on his own and or even to
know their rights to health care. In this instance, the nurse may
convey the client’s wish like change of physician, change of food,
upgrade his room or even to refuse a particular type of treatment.

5. Counselor. A nurse may provide emotional, intellectual and psychological
support. Nurses helps a client to recognize with stressful psychological or social
problems, to develop and improved interpersonal relationship and to promote
personal growth.
6. Change Agent. As a change agent, oftentimes a nurse change or modify nursing
care plan based on their assessment on the client’s health condition. This change
and modification will only happen when the intervention/s does not help and
improve a client’s health.
7. Leader. Nurse often assumes the role of leader. Not all nurses have the ability
and capacity to become a leader. As a leader it allows you to participate in and
guide teams that assess the effectiveness of care, implement-based practices,
and construct process improvement strategies.You may hold a variety of
positions like shift team leader, ward in-charge, board of directors, etc.

8. Manager. As a Manager, a nurse has the authority, power, and
responsibility for planning, organizing, coordinating and directing work
of others.They are responsible for setting goals, make decisions, and
solve problems that the organization may encounter. It is also the nurse
managers responsibility to supervise and evaluate the performance of
subordinates. The manager always ensures that nursing care for
individuals, families and communities are met.
9. Case Manager. A case manager is a primary nurse who provides direct
care to the client or family e.g. case manager for diabetic client.
10. Research Consumer. Nurses often do research to improve nursing care,
define and expand nursing knowledge.

Jarvis, C. (2016). Physical examination & health assessment. Seventh edition. St. Louis,
Mo.: Elsevier.
Patient’s Bill of Rights. http://samch.doh.gov.ph/index.php/patients-and-visitors-
corner/patients-rights#:~:text=1.,care%20at%20the%20relevant%20time.
(2008). Kozier & Erb’s Fundamentals of Nursing : Concepts, Process, and Practice.
Upper Saddle River, N.J. :Pearson Prentice Hall.

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