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Conjunctivae are clear without exudates or hemorrhage. Hair is of normal texture and evenly distributed.Įyes: Visual acuity is 20/20 without corrective lenses. Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Nailbeds pink with no cyanosis or clubbing. Skin: Skin in warm, dry and intact without rashes or lesions.
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Learn more about our online residency program we pair clinical and professional development to take advanced practice providers to the next level. With certain patients, you may need to note findings that are not included in this sample write-up. It’s meant to be a practical tool you can use in the clinical setting. In practice, you’ll want to document primarily on systems relevant to the patient’s history and presentation.įinally (disclaimer alert!), this post is not an exhaustive documentation reference. For purposes of a general overview, in this template we will give a down and dirty overview of each body system. In most cases, you do not need to examen and provide documentation for each and every body system. With time, you’ll learn to strike a balance when it comes to how much or how little to include in your chart. The amount you are paid for each patient encounter is based on your documentation, so cutting corners can directly affect your wallet. There is a fine balance between spending too much time on charting and including too little in your documentation. Under pressure to be efficient, most providers abbreviate physical exam documentation to just the necessities. It’s important to note that, well, in real-life documenting a physical exam doesn’t always happen exactly as you learned in school. Keep everyone in the loop by documenting exam findings and your next steps with the patient. Or, it allows for others to provide care in conjunction with yours without interfering with your part of the care plan. Documenting your findings and plan for the patient allows other providers to continue caring for the individual in your absence.
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How annoying is it when you’re expected to pick up where another provider left off only to find they left little more than two lines of handwritten chicken-scratch scrawled across the chart as to the patient’s situation? Don’t be that person. Second, documentation helps with continuity of care. Documenting your findings on a physical exam as well as the reasoning for your plan of care serves as a defense in the event another provider, patient etc. And, in the medical world, if you didn’t write it down, it didn’t happen. Okay, okay, incarceration might not be totally realistic, but there are plenty of scenarios in which your actions as a healthcare provider might be called into question. Documentation serves two very important purposes.