Sample Documentation
Open Resources for Nursing (Open RN)
Sample Documentation of Expected Findings
Patient’s skin tone appropriate for ethnicity. Skin warm and dry. Facial movements symmetrical. Nares patent without drainage. Uvula and tongue midline. Teeth and gums healthy. Able to swallow without difficulty. Trachea midline. No enlargement of lymph nodes.
Sample Documentation of Unexpected Findings
Patient has history of asthma and uses fluticasone inhaler daily. White patches present on tongue and inner buccal membranes. Dr. Smith notified at 1530 of presence of white patches on tongue and inner buccal membranes. Order for nystatin received and administered. Patient instructed to rinse mouth with water and spit out after using fluticasone to prevent reoccurrence of thrush.
