1.6 Sample Documentation
Open Resources for Nursing (Open RN)
Sample Documentation of Expected Findings
Mrs. Smith is a 65-year-old patient who appears her stated age. She is calm, cooperative, alert, and oriented x 3. She is well-groomed and her clothing is clean and appropriate for the weather. Her speech is clear and understandable, and she follows instructions appropriately.
Mrs. Smith moves all extremities equally bilaterally with good posture. Her gait is smooth and she maintains balance without assistance. Her skin is warm and her mucous membranes are moist. She is 5’4” and she weighs 143 with a BMI of 24 in the normal weight category. Her vital signs were BP 120/70, pulse 74 and regular, respiratory rate 14, temperature 36.8 Celsius, and pulse oximetry was 98% on room air.
Sample Documentation of Unexpected Findings
Mrs. Smith is a 65-year-old patient who appears older than her stated age. She appears slightly agitated during the interview. She is oriented to person only and denies pain. She is wearing a heavy winter coat on a warm summer day and has an unclean body odor. She is slow to respond to questions and does not follow commands. She seems to neglect the use of her right arm. Her gait is shuffled with stooped posture but has no assistive devices. She is 5’4” and weighs 102 pounds with a BMI of 17.5 in the underweight category. Her vital signs were 186/55, pulse 102 and irregular, respiratory rate 22, temperature 38.1 Celsius, and pulse oximetry was 88%.