Our head to toe physical assessments do not use "WNL" is not felt that is
appropriate. We have our assessments built as "normals" spelled out & other -
an optional query - for example:
Respiratory effort - no distress/no retraction or Other
Also for this purpose Meditech does have EMR ID's called Parameters for every
physical assessment for example:
Genitourinary Parameters
Hope this helps. A
"Renae Kendall/mhhcc.org" <[EMAIL PROTECTED]> wrote:
I too would be interested in this. Renae
Renae Kendall, RN
Clinical Systems Supervisor
Information Systems
Memorial Hospital and Health Care Center
Jasper, IN
812.481.0152
Fax 812.482.0541
"Romona E. Smith" <[EMAIL PROTECTED]> 08/06/07 08:53 AM
To
<[EMAIL PROTECTED]>, <[email protected]> cc
Subject
Physical Assessment Within Normal Limits
We are building EDM assessments and are working on a Physical Assessment. I
would like to document "Within Normal Limits" for each body system and then
have a more detailed assessment for those systems not within normal limits. I
have seen this discussed several times on the L. Does anyone have a policy they
would share defining what is "Within Normal Limits". I would also be inteterest
in your Physical Assessment.
Thank you,
Romona E. Smith, RN
Clinical Analyst
Anderson Hospital
Maryville, IL 62062
618-391-5278
[EMAIL PROTECTED]
AlidaLee Gingerich RN, BSN
Computer Cordinator
Yampa Valley Medical Hospital
970-871-2452
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