6.11 Sample Documentation
Open Resources for Nursing (Open RN)
Sample Documentation of Expected Findings
Patient denies any new onset of symptoms of headaches, dizziness, visual disturbances, numbness, tingling, or weakness. Patient is alert and oriented to person, place, and time. Dress is appropriate, well-groomed, and proper hygiene. Patient is cooperative and appropriately follows instructions during the exam. Speech is clear and facial expressions are symmetrical. Glasgow scores at 15. Gait is coordinated and erect with good balance. PERRLA, pupil size 4mm. Sensation intact in all extremities to light touch. Cranial nerves intact x 12. No deficits demonstrated on Mini-Mental Status Exam. Upper and lower extremity strength and hand grasps are 5/5 (equal with full resistance bilaterally). Follows commands appropriately. Cerebellar function intact as demonstrated through alternating hand movements and finger-to-nose test. Negative Romberg and Pronator drift. Balance is stable during heel-to-toe test. Tolerated exam without difficulty.
Sample Documentation of Unexpected Findings
Patient is alert and oriented to person, place, and time. Speech is clear; affect and facial expressions are appropriate to situation. Patient cooperative with exam and exhibits pleasant and calm behavior. Dress is appropriate, well-groomed, and proper hygiene. Posture remains erect in wheelchair, with intermittent drift to left side. History of CVA with left sided hemiplegia. Bilateral hearing aids in place with corrective lenses on. Pupils are 4mm equal and round. Reaction intact right and accommodation intact right eye. Left pupil 2mm, round nonreactive to light and accommodation. Upper extremity hand grips, nonsymmetrical due to left-sided weakness. Right hand grip and upper extremity strength strong at 4/5. Left lower extremity residual weakness, rated at 1/5, right lower extremity strength 4/5. Sensation intact to light touch bilaterally, R>L. Unable to assess Romberg and Pronator drift.