Health Assessment Observation

A common assignment on Health Assessment Observation is as follows:

1. Complete a 3.5- 4 page describing a health assessment observation that you have witnessed at your current practice setting or one in which you may be interested in working in after graduation.
2. A co-worker would be a fine patient for the final activity or a neighbor; the goal is to interview someone whose health history you do not know, as part of doing a physical assessment is being able to form a relationship with a patient and conduct an interview to collect a health history. Often times, the person you observe this week will agree to observe your final physical exam in the last week of class. So you might want to set up that commitment now.
3. Seek permission of the client to observe the historical assessment portion of the visit and reassure them that their privacy and confidentiality will be maintained at all times.
4. Identify the person with whom you observed and list their role.
5. Identify the date and location (i.e. hospital or clinic) where the observation took place.
6. Identify the type of client while maintaining complete confidentiality (i.e. 52 y.o. African American male presenting with shortness of breath - you may use patient initials but NO NAMES).
7. Detail the steps the nurse took in completing the assessment.
8. Was a particular assessment tool (form) used?
9. Did the tool cover all body systems?
10. Was this electronic or paper-based?
11. What techniques did the nurse use to obtain information from the patient?
12. Was information obtained via direct patient interview?
13. Was a questionnaire used?
14. How did the nurse use the information to identify problems and create a plan of care?
15. What did you feel went especially well during the process?
16. What recommendations would you make?
17. What do you feel from this experience you will use in your own practice now?