Briefly describe your practice setting and the typical patient population.

Exploring the nurse’s role in health assessment

My practice setting is an outpatient primary care clinic and I primarily care for adult patients. The subjective data points I typically collect when seeing a patient include their chief complaint, history of present illness, past medical and surgical history, medications including OTC supplements herbal products vaccinations, allergies intolerances, social history such as lifestyle habits (diet, exercise) and family relationships. Objectively, I obtain vital signs such as heart rate, respiratory rate & oxygen saturation; perform physical examinations; analyze lab results; review imaging studies if any have been done; and chart immunizations.

I document my findings in the electronic health record (EHR). During the visit I enter all information directly into the EHR using either computer or tablet technology depending on which room the patient is seen in and then utilize templates to generate standardized documentation that can be easily read by other healthcare providers.

Once complete with note documentation, I use data analysis techniques to formulate nursing diagnoses related to my patients’ conditions based on assessment findings noted previously including any underlying illnesses identified through labs etc.. In doing so it helps me formulating specific care plans for each individual that relies upon taking into account more than just disease processes& anticipated response there to alone but also patient-specific preferences+unique circumstances presented as well eventually leading me towards crafting most suitable interventions tailored around same apart from collaborating with providers during follow up stage should further management be required& referrals made where necessary too.