documenting accurately and appropriately in evidence-based research

documenting accurately and appropriately in evidence-based research

Discuss the following:

Please answer the following questions and include your rationale and evidence-based research to support your written work.

  • What does it means to document accurately and appropriately?
  • What are the documenting guidelines? When is it appropriate to use abbreviations?
  • What is the difference between subjective and objective data?
  • What does it mean to demonstrate clinical reasoning skills?
  • How can you use clinical reasoning to plan the organization of a comprehensive exam?
  • How will you document variations of normal and abnormal assessment findings?
  • What factors influence appropriate tools and tests necessary for a comprehensive assessment?
  • Reflect on personal strengths, limitations, beliefs, prejudices, and values.
  • How will these impact your ability to collect a comprehensive health history?
  • How can you develop strong communication skills.
  • What interviewing techniques will you use to interview the patient to elicit subjective health information about their health history?
  • What relevant follow-up questions will you use to evaluate patient condition?
  • How will you demonstrate empathy for patient perspectives, feelings, and sociocultural background?
  • What opportunities will you take to educate the patient?