10.4 Sample Documentation
Open Resources for Nursing (Open RN)
Sample Documentation of Expected Findings
Patient denies cough, chest pain, or shortness of breath. Denies past or current respiratory illnesses or diseases. Symmetrical anterior and posterior thorax. Anteroposterior-transverse ratio is 1:2. Respiratory rate is 16 breaths/minute, unlabored, regular, and inaudible through the nose. No retractions, accessory muscle use, or nasal flaring. Chest rise and fall are equal bilaterally. Skin is pink, warm, and dry. No crepitus, masses, or tenderness upon palpation of anterior and posterior chest. Lung sounds clear bilaterally in all lobes anteriorly and posteriorly. No adventitious sounds. SpO2 saturation 99% on room air.
Sample Documentation of Unexpected Findings
Patient reports shortness of breath for five to six hours. Patient has labored breathing at rest. Nail beds are cyanotic. Respiratory rate is tachypneic at 32/minute with neck and abdominal accessory muscle use. Lung expansion is symmetrical. Pursed-lip breathing noted with intermittent productive cough. Reports coughing up blood-tinged green sputum for two days. Anterior and posterior chest walls have no tenderness, masses, or crepitus upon palpation. On auscultation bilateral coarse crackles over lung bases. Expiratory wheezes are audible and heard with stethoscope scattered throughout lung fields. Pulse oximetry 93% on room air.