Sample Documentation

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 with no change in vision. Sclera in the left eye is pink, conjunctiva is read and yellow crusty drainage present. Patient able to read the newspaper without visual impairment. Dr. Smith notified and evaluated patient at 1400. Order for antibiotic eyes drops received and administered. Patient and family members educated to wash hands frequently to avoid spreading infection.