Documenting a Comprehensive Examination of Patients


One of the most important steps in assessing a patient is the interview, during which a care provider documents symptoms, family medical history, and other relevant data. Documenting appropriately and accurately means that a care provider should write down the details that are relevant to the assessment without changing the meaning. Documenting guidelines are used by institutions and healthcare systems to establish the rules of recording patient information. For instance, according to the Joint Commission (2018), care providers can use abbreviations in internal documentation but should avoid using them in informed consent forms, discharge instructions, and other patient documents.

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Discussion Board

During the assessment, care providers note both subjective and objective data. Objective data can be measured using reliable tools, whereas subjective data is the information reported from a person’s point of view. For example, the patient’s blood pressure is objective data, whereas their complaints about pain or discomfort are subjective. Demonstrating critical reasoning means collecting and analyzing information to conclude on the assessment plan, treatment, or diagnosis.

When planning for a comprehensive exam, care providers should use critical reasoning to establish the patient’s current needs and determine differential diagnoses. Based on the differential diagnoses and the patient’s current conditions, different tools and tests are chosen for the comprehensive assessment. Other factors influencing the choice of tools and tests, such as their cost, waiting times, and reliability, should also be taken into account. Once test results are received, care providers should document variations of normal and abnormal assessment findings in the patient’s medical record, as this would allow other team members or specialists to view them.

My strengths are critical thinking and good problem-solving ability, and my limitations are average communication skills and attention to detail. I am not a religious person, but I do not have any prejudice towards people from other cultures and religions. My values are equality, diversity, kindness, and care. Some of these factors might affect my ability to collect a comprehensive health history. For instance, my limitations might lead me to miss some important details about a patient. To improve communication skills, it would be useful for me to go through communication skills training since there is evidence in support of this method (Moore, Rivera, Bravo-Soto, Olivares, & Lawrie, 2018).

To improve the outcomes of patient interviews, I will use various communication and interviewing techniques, such as active listening, nonverbal communication, and adaptive questioning (Bramhall, 2014). Relevant follow-up questions to ask patients to evaluate their condition are, “Have your symptoms improved since our last appointment?”, “Have you experienced any side effects from medications?”, “Have you taken the medications as prescribed?”, and “Do you feel like the treatment worked for you?”. These questions will help in determining whether or not the patient’s condition is improving, as well as in identifying any adverse effects from medications.


Patient education is another critical component of high-quality care since it engages patients in the process and encourages them to take action to improve their health. I will take the opportunity to educate a patient when they are showing evidence of an unhealthy lifestyle, are starting a new treatment regime, or ask questions related to their health. For example, when prescribing a new treatment, patient education is essential to promote adherence (Usherwood, 2017).

If patients have dangerous habits, such as smoking or alcohol use, care providers should also inform patients about their potential consequences and support resources available in the community, including smoking cessation specialists or substance use counseling.

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Bramhall, E. (2014). Effective communication skills in nursing practice. Nursing Standard, 29(14), 53-60.

The Joint Commission. (2018). Use of codes, symbols, and abbreviations. Web.

Moore, P. M., Rivera, S., Bravo‐Soto, G. A., Olivares, C., & Lawrie, T. A. (2018). Communication skills training for healthcare professionals working with people who have cancer. Cochrane Database of Systematic Reviews, 7(1), 1-83.

Usherwood, T. (2017). Encouraging adherence to long-term medication. Australian prescriber, 40(4), 147-150.

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