A & O x3, no c/o pain, 0 on 0 -10 scale. moves all extremeties with equal strength. Resp even & unlabored, Apical heart rate strong with no abnormalities observed. Lungs clear Ant. and Post. Abd flat, soft and nontender. BS normal x 4 quads. LBM in A.M. Void clear, yellow without difficulty or pain. Cap refill <3. Pedal and radial pulse 3+. Skin warm, dry and mucousa pink.
That is a little better.
0800 Vitals: HR 87, RR 12, T 98.6, BP 120/80.
A&Ox3, no c/o of pain, 0 out of 0-10, ten being worst pain experienced. Speech is clear, PERRLA. Skin warm, clean, intact, dry and mucousa pink. Moves all extremities with equal strength. Hand graps are equal and strong bilaterally. Lung sounds clear. Respirations even and unlabored. Heart sounds clear and regular. Bowel sounds active in all 4 quads, abd flat, soft, and non-tender to palpation. Last BM 10/10/2010, brown, soft formed. Urine clear yellow with out difficulty or pain. Pedal pulses +3 bilaterally. Cap refill < 3 sec. Patient denies any needs, call light left with in reach. ------Anonymous1919, LPN
That's how I write out my assessments. I didn't know how else to tell you how to fix certain things with out showing you, so I hope that's okay. I know some would say "Don't do work for other people", but I promise that's not what I was trying to do.