Ear documentation

[ofcruz]

WE have to document in paragraph form with subjective first then our physical finding (objective). I covered the eyes and would like any tips/pointers in making my documentation better and more coherent. Thank you.

PS, Did I forget anything in the assessment.

Client is a 20 year old female whom is alert and responsive to questions. She is very assertive and seems coherent. Ears: Client denies any hearing loss, exposure to load noises, pain, discharge, infection tinnitus, or vertigo. Ears are intact, 2 total, pinnae crosses EOL, bilaterally symmetrical, vertically attached, brisk elastic recoil, with piercing on both lobules, tan, with a ruby red cherry angioma behind left auricle without masses, deformities or discharge; External ear canal clear without swelling, lesions, discharge; Left and Right TM intact, pearly gray, with light reflex and landmarks clearly visible without perforations, erythema, lesions; Weber test: no lateralization. Rinne test: AC