I am a first semester nursing student, and am struggling to write my ROS on a nursing home pt. She is straight psych (dementia, dep, anx) with no other medical complications. She was pretty uncooperative with just about everything, straight up refused her normal shower, but she was orientated x3. She allowed vital signs to be taken, and even joked about the fact we couldn't find her radial pulse (laughed about it, so I do know she was joking).
Due to her lack of cooperation, I couldn't really examine her bowel sounds and such, and her chart had no information about anything ever being abnormal with any system other than her general dementia, irritation, depression (asymptomatic atm) and anxiety.
How would I fill out the paper work for this...? Any examples (normal or not) would be IMMENSELY appreciated!