Objectively Speaking

Jacky Vaniotis, RN, NREMT-P

In the previous issue of this Journal, we started a series of articles on documentation. In the first of the series, we looked at documenting the Subjective findings of an exam: getting a quick but complete history from the patient and/or others at the scene, and writing it down in a clear, concise, and readable format. In this issue we're going to look at documenting our Objective findings, those which we see, feel, hear, smell, and otherwise experience with our own senses, without the need of somebody providing any information for us.

A review of run sheets from many providers at various levels will find that, just as with subjective findings, objective findings often are very vague, if present at all. Why? I'd hate to think that maybe it's because people don't do a thorough assessment! While the causes for this scarcity of documentation are unclear, they are easily remedied. Remember what we discussed in the last issue: good patient care leads to good documentation which leads to good patient care! If we know we are going to have to write it down, we will examine it, and once we have examined it, we are able to write it down. Documenting the objective findings is perhaps the easiest part of writing a run sheet, assuming we do a good physical exam. If, however, we skimp on our physical assessment, we will have very little to document in the objective section of our run sheet.

There's really no mystery about how to write this portion of our report. We simply need to describe our objective findings exactly as we experience them. That's all there is to it. What is the first thing we note when we approach a patient? It's the patient's overall general appearance, right? Maybe the patient is elderly, pale, sitting in a chair, sweating profusely; perhaps the patient is a teenager, laughing with friends, holding an ice pack on her ankle. We begin the objective part of our narrative by describing in writing exactly what we saw in that first glance, what the authors of the National Standard Curriculum called the "First Impression." This begins painting the picture of what the patient looked like before we began treatment.

The next four things we evaluate on every patient, during the so-called Initial Assessment, are level of consciousness, airway, breathing, and circulation. These, too, can easily be written down in exactly that order, since that's the order in which we assess them. "Patient alert, oriented x 3. Respirations even and  non-labored. Skin pink, warm and dry. No bleeding noted." That has succinctly described for the reader the patient's mental and ABC status, and that completes the summary of our findings from our Initial Assessment. (See Figure 1.)

The next step of any organized exam, after we complete our Initial Assessment, is to do either a head-to-toe exam, if the patient's situation requires it, or to focus on more isolated systems if that is more appropriate. In the 1994 National Standard Curriculum terminology, this is the Focused Physical Exam. For any patient who is unconscious or who has a significant mechanism of injury, the "focus" is the entire body, so we would do the full head-to-toe exam. (See Figure 2.) For anybody with a minor trauma or an isolated medical complaint, the focus is much narrower, and we might elect to look only at the system in question.

So, assuming we are caring for a patient who is unconscious or who has significant medical or trauma issues, we would document our findings in exactly the same order as we examined them during our well-organized patient assessment. Did we find anything wrong with the patient's head or face? How about the neck? The chest? The abdomen? And so on. It's easy enough to divide the findings from each of these body areas with punctuation, as noted in Figure 3. We must address all areas, not just those with positive findings. I would also go so far as to say we should specifically state when we have a lack of pertinent findings from each body area separately. In other words, it's not sufficient to make the general statement, "no injuries found," because that does not document that we evaluated each area. It also leaves a question in the readers' minds as to whether no injuries were found because they weren't searched for or because they weren't present.

Both assessment and documentation are actually very straightforward for an unconscious patient, or for a trauma patient with a significant mechanism of injury -- essentially we document findings (including pertinent negatives) on every body area, head to toe. It becomes a bit more complicated, however, when we're dealing with a medical patient, and requires us to think more about systems and how they are interrelated. So, for example, if we are evaluating a conscious and alert cardiac chest pain patient, we must be thinking about what body areas we must physically inspect. While it may not always be appropriate or necessary to completely "expose" the patient, we do need to know when it is, and what areas specifically to assess when it isn't. (See Figure 4.) This, of course, requires us to be thinking beyond what is obvious. The patient might not think to point out her swollen ankles; we must think to look for them. The patient also might not think to complain of congestion in her lungs; we must think to auscultate for that. This is actually reminiscent of what we have to do in gathering the subjective (history) component of our documentation -- go beyond what the patient offers and actively search for what we need to know.

While our initial training at any level teaches us the very basics of assessment and documentation at that level, we must challenge ourselves always to be expanding our base of knowledge. A First Responder fresh out of class might not have the background to look for pedal edema in a patient with a history of heart failure, but a paramedic fresh out of class certainly should. And perhaps a First Responder or an EMT-Basic who attends a continuing education session covering heart failure would too. The more we learn the better we become within our scope of practice, both at assessing and caring for patients.

In summary, being able to do thorough documentation of objective findings requires that we do a thorough and appropriate physical exam. Assuming our exam was comprehensive and well-organized, we can write our objective findings exactly as we encountered them, beginning with the Initial Assessment (general appearance, level of consciousness, and ABC's) and continuing with the Focused Physical Exam. From that exam we will have enough information to be able to paint a very organized and descriptive picture of how our patient presented.

In future issues of this Journal, we will continue this series on documentation by looking at the "Patient's Suspected Problem" area of the run sheet, documenting our treatment plan, and pitfalls and problems frequently found in our documentation.

© 2004 by Jacqueline B. Vaniotis