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Discussion

Simple DOCUMENTATION question

After we do the head to toe assessment, how are we supposed to document it if everything is normal? Are we supposed to write "everything normal"?? That doesn't seem right.

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  • Expert

you either write things are "normal" or write what you have observed. ex: lungs clear to ausculation, respirations regular and unlabored, abdomen soft with bowel sounds ausculatated in all 4 quadrants.

you can read examples of nursing documnetation on posts #17, #19 and #20 of this sticky thread: https://allnurses.com/nursing-student-assistance/nursing-documentation-168921.html - nursing documentation

  • Author

Thanks so much.

at all the hospitals I've been to thus far, we've charted "WNL" (within normal limits) for assessments of normals.

Eg) if lung sounds were clear throughout all fields, that was WNL. Same if capillary refill was less than 3 secs, or HR was 60-90bpms, etc.

All institutions that I've been to have had computer charts/computers on wheels to chart (MEDITECH or some other system that their IT department developed) and all charting options you selected from a drop down menu. However, there was always a box where we could add in a note or the like to describe an abnormal in depth if need be.

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