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Discussion

Need help with documenting

I need help with documenting what is normal. Our lab instructor didn't give us any real direction on how to describe what normal is. She only told us to use very descriptive words instead of broad terms(normal, pink, symmetrical.) Our first assignment is due next week over the hair,head, face and nails only using inspection; I have no idea where to start. How do you describe the symmetry of a normal face(eyes, nose, lips.) What type of words would be good to use. Thank you.

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    Here's what I do from my head to toe charting info. I would get a book on Charting, like Made Incredibly Easy, it really helps.

    Alert & oriented x3, speech clear, cooperative and relaxed. Hair clean, slight dry. Thinning. No lesions on scalp. No tenderness reported. Face: skin color pink, no edema. PERLLA, 2mm. Wears glasses for reading. Conjunctiva pink bilaterally. Ears with wax buildup, no drainage. Wears hearing aides bilaterally. Able to hear whispered sentence at 3 feet. Nasal passages patent. No lesions or abnormal drainage. Lips and Mucous membranes pink and moist. No lesion redness or tenderness. Wears bottom dentures; no reports of discomfort.

    You would just change what is needed, for instance for normal, I would not mention the hearing aides...

    When you are charting about nails, note any clubbing, cap refill, color and texture.

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    Thanks for the help, I really appreciate it.

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    that is good advice for while you are in school. once your out it depends on the hospital, we chart bassed on exception so we say WNL except for...... or no change except for.....It gets alot easier.

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