Sample Documentation

Sample Documentation of Expected Findings

Skin is expected color for ethnicity without lesions or rashes. Skin is warm and dry with no edema. Capillary refill is less than 3 seconds. Normal skin turgor with no tenting.

Sample Documentation of Unexpected Findings

Mother brought the child into the clinic for evaluation of an “itchy rash around the mouth” that started about three days ago. Crusted pustules present around the patient’s mouth. Dr. Smith evaluated the patient and prescription for antibiotics provided. Mother and child educated on good hand hygiene practices to prevent spread of infection.