How do I document an Heent exam?

Documenting a normal exam of the head, eyes, ears, nose and throat should look something along the lines of the following:

1. Head – The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring.
2. Eyes – Visual acuity is intact.

How do you document general appearance in nursing?

Appearance

1. Age: Does the patient appear to be his stated age, or does he look older or younger?
2. Physical condition: Does he look healthy?
3. Dress: Is he dressed appropriately for the season?
4. Personal hygiene: Is he clean and well groomed, or unshaven and unkempt, with dirty skin, hair or nails?

How do you describe a patient’s appearance?

General Appearance Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.

How do you document an assessment?

An assessment report should accomplish the following:

1. Outline the student learning or program outcomes or goals assessed during the assessment cycle timeframe.
2. Identify and describe the specific assessment method(s) and tools used to gather evidence for the outcomes or goals.
3. Identify the specific source(s) of the data.

How do you document the integumentary assessment?

There are five key areas to note during a focused integumentary assessment: color, skin temperature, moisture level, skin turgor, and any lesions or skin breakdown.

How do you document normal cardiac assessment?

Documentation of a basic, normal heart exam should look something along the lines of the following: The external chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal.

What is focused nursing assessment?

Focused assessments are nursing assessments that target the specific body system where the patient demonstrates a problem, disorder, or concern. This can relate to one or multiple body systems. You’ll most often see these performed in emergency departments when a patient presents for a specific issue.

What are the methods of documentation in nursing?

In this section, three main documentation methods are presented: charting by exception, narrative, and nursing process.