Sample Documentation

Sample Documentation of Expected Findings

Mrs. Smith is a 65-year-old patient who appears her stated age. Calm, cooperative, alert, and oriented x 3.  Well-groomed with clean clothing and appropriate for weather. Speech is clear, understandable, and follows instructions appropriately. Moves all extremities equally bilaterally with good posture. Gait is smooth and maintains balance without assistance. Skin warm and mucous membranes moist. 5’4” and weighs 143 pounds with BMI of 24 in normal weight category. Vital signs: BP 120/70, pulse 74 and regular, respiratory rate 14, temperature 36.8 Celsius, SpO2 98% on room air.

Sample Documentation of Unexpected Findings

Mrs. Smith is a 65-year-old patient with older appearance than stated age. Slightly agitated during the interview. Oriented to person only and denies pain. Wearing a heavy winter coat on a warm summer day and unclean body odor. Slow to respond to questions and does not follow commands. Neglect noted of right arm. Gait shuffling with stooped posture with no assistive device. 5’4” and weighs 102 pounds with BMI of 17.5 in the underweight category. Vital signs: BP 186/55, pulse 102 and irregular, respiratory rate 22, temperature 38.1 Celsius, and SpO2 88% on room air.