8.4 Sample Documentation
Open Resources for Nursing (Open RN)
Sample Documentation of Expected Findings
The patient reports no previous history of ear or eye conditions. Eyes have white sclera and pink conjunctiva with no drainage present. Corrected vision with glasses using Snellen chart is 20/20 bilaterally. Ear canals are clear bilaterally. Whispered voice test indicates effective hearing with the patient reporting five out six numbers correctly for both ears. Patient demonstrates good balance and coordinated gait.
Sample Documentation of Unexpected Findings
The patient reports awakening with an irritated left eye and crusty drainage but no change in vision. The sclera in the left eye is pink, the conjunctiva is red, and yellow, crusty drainage is present. The patient is able to read the newspaper without visual impairment. Dr. Smith was notified and she evaluated the patient at 1400. A new order for antibiotic eye drops was received and administered. The patient and their family members were educated to wash hands frequently to avoid contagion.