Emart

I'm sharing these examples of a head to toe assessment with negative and positive findings. Please post any suggestions on what you think is important to add. NEGATIVE FINDINGS General Appearance • Observation: The patient appears alert, oriented, and well-nourished, sitting comfortably with a relaxed posture and good eye contact. No signs of distress. Head and Face • Skull and Scalp: Normocephalic and atraumatic. Scalp is clean and free of lesions. • Facial Symmetry: Symmetrical facial movements with no drooping or abnormalities. • Eyes: Pupils are equal, round, and reactive to light and accommodation (PERRLA). Sclera is white, and conjunctiva is pink and moist. • Ears: External ears are symmetrical and free of lesions. Ear canals are clear with no discharge; tympanic membranes are intact and pearly gray. Hearing is intact bilaterally. • Nose: Nasal passages are patent without septal deviation; mucosa is pink and moist. No sinus tenderness on palpation. Mouth and Throat • Lips: Pink, moist, and free of lesions. • Oral Mucosa: Pink, moist, and intact with no lesions. Tongue is midline and well-papillated. No signs of thrush. • Teeth and Gums: Teeth are in good repair; gums are pink and firm without swelling or bleeding. • Pharynx: Pharynx is clear, with no erythema, swelling, or exudates. Tonsils are not enlarged. Neck • Trachea: Midline with no visible swelling. • Thyroid: Non-palpable and without enlargement or nodules. • Lymph Nodes: No cervical lymphadenopathy; lymph nodes are non-tender and not palpable. Respiratory System • Inspection: Symmetrical chest expansion with normal respiratory effort; no use of accessory muscles. • Auscultation: Clear breath sounds bilaterally in all lung fields without wheezes, crackles, or rhonchi. • Percussion: Resonant throughout lung fields. • Palpation: No tenderness or masses. Cardiovascular System • Auscultation: Regular rate and rhythm (RRR) with no murmurs, gallops, or rubs. • Peripheral Pulses: 2+ (normal) in all extremities bilaterally; no carotid bruits. • Edema: No peripheral edema. Abdomen • Inspection: Flat and symmetrical with no visible masses or lesions. • Auscultation: Normoactive bowel sounds in all four quadrants. • Percussion: Tympanic throughout with no areas of dullness. • Palpation: Soft, non-tender, and without organomegaly or masses. Musculoskeletal System • Inspection: Normal curvature of the spine; no swelling, redness, or deformities in joints. • Palpation: No tenderness over the spine or joints. • Range of Motion (ROM): Full ROM in all extremities without pain or crepitus. Neurological System • Mental Status: Alert and oriented to person, place, and time. Speech is clear and coherent. • Motor Function: 5/5 muscle strength bilaterally in upper and lower extremities. • Reflexes: 2+ reflexes bilaterally and symmetrical. No clonus. • Cranial Nerves: Cranial nerves II-XII are intact. Skin • Inspection: Skin is warm, dry, and intact with uniform color. No rashes, lesions, or bruising. • Temperature and Moisture: Normal temperature; skin is not excessively dry or moist. • Wounds: No open wounds or signs of pressure ulcers. POSITIVE FINDINGS General Appearance • Observation: The patient appears lethargic and disoriented, with slumped posture and minimal eye contact. Head and Face • Skull and Scalp: No visible lumps, lesions, or abnormalities. • Facial Symmetry: Facial asymmetry noted; the left side of the face appears droopy. • Eyes: Pupils are unequal (anisocoria); the left pupil is 4 mm and sluggish to light, while the right pupil is 3 mm and reactive. • Eyelids: Slight ptosis of the left eyelid. • Conjunctiva and Sclera: Conjunctiva is pale, suggesting possible anemia; sclera is yellowish, indicating jaundice. • Ears: Mild erythema and discharge from the right ear canal; decreased hearing on the right side. • Nose: Nasal congestion with a deviated septum to the right; slight tenderness on palpation of the maxillary sinuses. Mouth and Throat • Lips: Dry and cracked, indicating dehydration. • Oral Mucosa: Pale with white patches on the tongue and inner cheeks, suggestive of oral thrush. • Teeth and Gums: Several dental caries noted; gums are red, swollen, and bleed upon light palpation. • Pharynx: Erythema and swelling present; tonsils are enlarged with white exudates. Neck • Trachea: Midline but there is noticeable swelling on the right side of the neck. • Thyroid: Enlarged, with palpable nodules. • Lymph Nodes: Anterior cervical and submandibular lymph nodes are tender and enlarged. Respiratory System • Inspection: Asymmetrical chest expansion noted on inspiration. • Auscultation: Diminished breath sounds in the right lower lobe; crackles heard on both bases, suggestive of fluid accumulation. • Percussion: Dullness over the right lower lung field. • Palpation: Tenderness over the left upper anterior chest wall. Cardiovascular System • Auscultation: Irregular heart rhythm; grade 3/6 systolic murmur heard at the left sternal border. • Peripheral Pulses: Diminished dorsalis pedis and posterior tibial pulses bilaterally. • Edema: Pitting edema observed in the bilateral lower extremities (2+). Abdomen • Inspection: Distended abdomen with visible veins. • Auscultation: Hypoactive bowel sounds present in all four quadrants. • Percussion: Tympany noted throughout with dullness in the flanks, suggestive of ascites. • Palpation: Rebound tenderness in the right lower quadrant; positive Murphy's sign indicating possible cholecystitis. Musculoskeletal System • Inspection: Swelling and erythema noted in the right knee joint. • Palpation: Tenderness over the lumbar spine. • Range of Motion (ROM): Limited ROM in the right knee with pain on movement. Neurological System • Mental Status: Disoriented to time and place; speech is slurred. • Motor Function: Weakness noted in the left upper and lower extremities (3/5 strength). • Reflexes: Hyperreflexia in the right upper extremity. • Cranial Nerves: Cranial nerve VII deficit (facial nerve) on the left side; drooping of the mouth. Skin • Inspection: Jaundice present; several bruises on the arms and legs at varying stages of healing. • Temperature and Moisture: Skin is cool and clammy. • Wounds: Pressure ulcer on the sacrum, stage 2.

PCC - point click care

Is this a good example for discharge documentation? I met with resident and explained discharge instructions and medication list. Resident verbalized understanding. Call received from daughter and explained all discharged instructions as well. Daughter verbalized understanding. At time of discharge resident was stable and had no complain of pain or discomfort. Resident discharged home with Home Health Services, HHA/RN/PT/OT, Prescriptions and all personal belonging . Resident is encouraged to follow up with PCP. in one week of discharge. Resident was assisted by CNA until resident reached to their transportation. (Family car) Family expressed satisfaction with their stay in the facility.

Is this a good progress note for a patient transfer to a Hospital? Any suggestions... CNA reported to me that the resident had three episodes of coffee ground emesis this morning. The resident was checked in the room and was sitting in a wheelchair. I transferred the resident to bed from the wheelchair and elevated the head of the bed to 45 degrees. I repositioned the resident to the right side to prevent aspiration. Vital signs were as follows: BP 120/80, P 88, Temp 98.6, Resp 18, O2 98%. The resident complained of stomach discomfort. I called Dr. X and reported the condition, and he ordered the transport of the resident to X hospital via regular ambulance. I called Maria, the resident's daughter, and informed her of the condition and the order to transfer the resident to hospital. I explained the Bedhold policy, and she understood. I called ABC Ambulance for transport. I called X hospital, spoke to nurse Betty and gave her report about the transfer and the condition of the patient. The ambulance arrived at 1400, picked up the resident, and left via stretcher accompanied by two paramedics. Safety and comfort were maintained.

Is this a good example for daily Progress Notes? Any suggestions welcome. Nurse's Notes The resident is resting comfortably in bed, with fall precautions properly implemented. The call light is within easy reach, and the resident shows no signs or symptoms of pain or distress. The resident is alert, oriented to person, place, and time, and remains in stable condition. All prescribed medications have been administered as per the physician's orders and were well tolerated. Assistance with activities of daily living was provided by the CNA. The IV access site is patent with no signs of infection or infiltration. The O2 nasal cannula is positioned correctly, and the resident is maintaining adequate oxygen saturation levels. The NG tube is secured in place, with no signs of displacement or discomfort noted. The Foley catheter is draining clear urine, and there are no signs of blockage or infection. The colostomy site is clean and well-maintained, with the stoma appearing healthy and the appliance securely attached.

Is this a good example for documenting a new admission? New Admission Notes: Resident NAME is a ____-year-old female/male admitted to Room _____ from WHAT HOSPITAL? via stretcher, accompanied by two paramedics from WHAT AMBULANCE COMPANY? The resident is under the care of Dr. ______. Primary Diagnosis: ________. Secondary Diagnoses: ________ (List all secondary diagnoses). The resident is AAOX? and PERRLA. Respirations are even and unlabored with clear lung sounds bilaterally, no shortness of breath noted. The resident is incontinent of bowel and bladder. Skin is warm to the touch. Resident has a left heel injury, redness on the right heel, left armpit rash, dorsal rash, perineal redness, and bilateral upper extremities bruising. The resident does not have dentures or hearing aids but does wear glasses. Vital signs are within normal limits: BP: _____, Pulse: ___, Oxygen Saturation: ___%, Respirations: ___. The resident denies any pain or discomfort at the time of the assessment. Abdomen is soft, non-tender, and non-distended to palpation, with bowel sounds present in all quadrants. The resident was oriented to their room. The CNA assisted with clothing change, provided hygiene, and completed the resident's inventory. The bed is in the lowest position with the head of the bed elevated 30-45 degrees, and the call light is within easy reach. The resident was instructed to call for assistance and verbalized understanding. Plan of care is ongoing.