Documentation Help PLEASE!

[pixiebuddymick]

Hello!

New to the forum because I browse it frequently while studying looking for bits of info and decided it was time I join. On Tuesday, yes, coming up WAY too soon... I have a final return demonstration of a Head to Toe assessment. I have been practicing in advance and writing up my documentation to make sure I have the correct information. I already went to my lab instructor to review the documentation but I still have questions. I will post my documentation below. Basically, we are told what we have to assess, have to recall it and perform it without any notes, and document it without any notes. So we were told to memorize our documentation. We are given a paper that has the systems we are assessing listed, and we document according to system. Here are my questions....

1. We have to name each cranial nerve we are assessing. We are only assessing II, III, IV, VI, VII, VII, VIII, IX, X, XI, XII. Originally, I had under Neuro that Cranial Nerves blah blah blah were intact. Now, I am told we ALSO have to include the cranial nerve in the other systems. How do I do this? I feel like it gets very wordy and sounds awkward.

2. Under Ears, Mouth, and Nose, my instructor wrote "type" next to "client is able to hear whispered two-syllable word bilaterally while putting pressure on opposite tragus". What do you mean "type"? Type of pressure? I'm lost.

3. Under Head, Neck, and Face... instructor says it should NOT say rotation in "neck rotation and shoulder shrug resistance against strength 5+". She said it should be ROM. But this isn't necessarily range of motion, it is the muscle strength grading? Or is this testing of the spinal nerve in which it is a totally different concept?

If we do not pass this we do not pass the class. I want my documentation to be absolutely perfect. Everything has to be detailed. I have looked up documentation online and what I have found would NOT fly in my class because basically we have to explain every single step like they have no idea what we are talking about. Has to be VERY clear. Any advice is GREATLY appreciated! Thank you and Happy Thanksgiving.

Integumentary System

Skin is warm, moist, and dry to the touch throughout. Smooth and even tone to skin throughout; anterior and posterior, no nevi. Skin color is beige with pink undertones. Hair is of natural color and is free of pest inhabitants. Scalp is even throughout, no lesions or dandruff. Turgor return is prompt, skin is elastic, no lesions. Patient shaves legs.

Health Promotion: Used sunscreen on exposed areas of skin in the winter when going outside.

Head, Neck, Face

Skull is symmetrical and normocephalic. No lumps, lesions, or tenderness. Hair on scalp is distributed evenly throughout and soft. Trachea is midline without deviation. Face is symmetrical with no drooping bilaterally. Thyroid not palpable. Frontal and maxillary sinuses not tender to palpation. Preauricular, postauricular, occipital, superficial cervical, jugulodigastric, submandibular, submental, deep cervical chain, posterior cervical, and supraclavicular lymph nodes not palpable. No warmth, tenderness, or edema in neck. Neck rotation and shoulder shrug resistance strength 5+.

Health Promotion: Wear a helmet when you ride horses.

Ears, Mouth, Nose

Nose is midline with no lesions. Patency in nares bilaterally. Ears are symmetrical, with no thickening of the skin bilaterally. Pinpoint lesion on earlobe bilaterally. Client is able to hear whispered two-syllable word bilaterally while putting pressure on opposite tragus, verifying Cranial Nerve VIII (Acoustic) is in tact. Buccal mucosa is moist, pink, and free of lesions. Teeth are white and straight. No caries present. Uvula rises midline with phonation. Tonsils 1+.

Health Promotion: Brush teeth twice daily and after meals.

Eyes

Cranial Nerve (Optic) I in tact, verified by Snellen chart with results of 20/20 OS, 20/20 OD, 20/20 both. Cranial Nerves III, IV, V (Oculomotor, Trochlear, Abducens) in tact verified by Cardinal Position Test. Peripheral vision intact. Pupils measure 5mm bilaterally. Pupils are equal, round, and respond to light and accommodation. Sclera is white, conjunctiva is translucent. Iris is flat and round with even coloration. Cornea is smooth and clear.

Health Promotion: Wear sunglasses daily when going outside.

Thorax/Lungs

Anterior and posterior chest symmetrical bilaterally. Elliptical shape with downward sloping ribs. Patient is sitting in a relaxed posture. No lumps, tenderness, or warmth on posterior or anterior chest bilaterally. No lumps, masses, or tenderness upon palpation of spinous process. Bronchovesicular breath sounds heard bilaterally posteriorly and anteriorly. No abnormal or adventitious breath sounds bilaterally posteriorly and anteriorly. Respiration is regular, unlabored, thoracic, regular depth, at a rate of 12 respirations per minute. Anterior/posterior transverse diameter is 1:2. No lumps, tenderness, or warmth in anterior or posterior chest bilaterally.

Health Promotion: Avoid second-hand smoke

Abdomen

Abdomen is flat and symmetrical, absence of pulsations. Active bowel sounds in all quadrants. No bruits heard over aorta. Tympany heard upon percussing. Patient denies tenderness and does not guard during palpation. Abdomen is soft and palpable with no organomegaly or masses. Spleen not palpable. No CVA tenderness bilaterally.

Cardiovascular/PVS

Right and left corotid artery 2+. No bruits hear bilaterally. Radial and brachial pulse 2+ bilaterally. Posterior tibial and dorsalis pedis 2+ anteriorly. No edema or pitting edema bilaterally. No jugular distension detected at 30 degrees bilaterally. No heaves, pulsations, or lifts. Patient denies tenderness in chest. No pulsations or thrills palpated over heart. Apical impulse not palpable. Apical rate was 76 bpm. No extra or abnormal heart sounds.

Nail beds on all 20 digits pink. No clubbing with a profile sign of less than 160 degrees. Capillary refill of less than 3 seconds in one digit on each hand and foot. No edema found bilaterally.

MS

Patient has full range of motion in all joints assessed; neck, shoulders, elbows, wrists, digits, spine, hips, knees, and ankles bilaterally upper and lower extremities. No lordosis, kyphosis, or scoliosis observed. Normal spine curvature. Joints and muscles symmetric bilaterally; no swelling, warmth, crepitus, masses, or tenderness. Muscle strength 5+ in neck, shoulders, and upper extremities bilaterally.

Neurological

Negative Babinski sign. Negative Romberg sign. Speech, appearance, and behavior appropriate to the setting. Patient identifies sharp and dull touch bilaterally. Patellar reflex 2+ bilaterally. Firm grasp bilaterally.

Cranial Nerves II, III, IV, VI, VII, VIII, IX, X, XI, XII intact.

Patient is alert and oriented to person, place, and time.

[LoriRNCM, ADN, ASN, RN]

Skin is moist AND dry? Wow, that is a huge assignment. Good luck!

[JustBeachyNurse, LPN]

Wow. I've seen medical residents have less info in a full patient assessment.

Moist & dry? Moist skin is diaphoretic usually I see skin is grossly intact turgor WNL (I was taught turgor = elasticity) so you have a lot of duplication. Without dental xrays you cannot affirmatively say no caries present you can only state no visible caries.

[pixiebuddymick]

Skin is moist AND dry? Wow, that is a huge assignment. Good luck!

Whoops! See that's why I was wondering if anybody else saw anything that jumped out. After reading it so much it becomes a sea of words. Thank you.

[pixiebuddymick]

GOOD point. I suppose dental X-rays would be necessary. I think we are mainly looking for the presence of visible fillings. And for turgor the way they have showed us documentation is to say the skin is elastic and also discuss the turgor. Yeah it is a lot... Overwhelming at times. Any other major duplications jumping out at you? Thanks.

[StudentOfHealing]

That is one heck of an assessment. I'm glad I wasn't the only to think so! C:

[pixiebuddymick]

I know! Talk about some ANXIETY! I am afraid I will forget something. And don't forget I still have to do the actual assessment..... ahhhh!

What I really, really, REALLY wish had been provided for us was an example. Just one! I've been scouring the internet, putting the sections from my textbook together to double check, re-watching the videos.... just still seems like so much information.

[SopranoKris, MSN, RN, NP]

Unfortunately, grading on assessment documentation seems to be very subjective. I've had 4 assessment reviews where one instructor said there were no revisions to make, while another one picked it apart. SAME wording, too! It drives me insane.

I wish I could provide more insight. All I can say is, follow what your lead instructor wants because he/she ultimately determines your grade.

[pixiebuddymick]

Well I have made some MORE corrections. Realized neck and spine are not bilateral, they are medial, so they would not have full ROM bilaterally.... and a couple other things. What I am now doing is posting each section on a forum on our school page in hopes of having it reviewed and critiqued by the person grading it because at SopranoKris pointed out, this grading is very subjective.