Question

List the parts of the patient's chart that assist the nurse in the collection of patient data

Answer 1

Ans) Subjective Data:

- Information collected form residents, family members, or friends; information may or may not be true but it is what person reported, also called symptoms .ie - "Ms. Jones says her foot is itchy."

Objective Data:
- Observable, measurable (see, touch, hear, smell). Objective data that can be recorded.

Primary Source:
- Patient is primary source from which to collect data. Must be alert & oriented.

Secondary Source:
- Include family members, significant others, medical records, diagnostic procedures, & nursing literature when the patient is unable to supply informaton because of deterioration of mental status, age, or seriousness of illness. Other healthteam professsionals also help.

Biographic Data:
1st method of data collection. Name, gender, address, date of birth, birthplace, occupation, reason patient is seeking health care, a history of present illness, health history, & family history.

Physical Examination:
2nd method of data collection. An assessment of each part of the pt's body to obtain objective data about the pt that assists in determining the pt's state of health. Also guided by subjective data provided by the patient. Statement of pain from patient is followed by examining that part of the body, etc.