9.5: Sample Documentation — Read

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Sample Documentation of Expected Findings

The patient denies abdominal pain, nausea, vomiting, bloating, constipation, diarrhea, urinary pain, urgency or frequency, change in appetite, food intolerance, dysphagia, or personal or family history. Abdominal contour is flat and symmetric. No visible lesions, pulsations, or peristalsis noted. Bowel sounds present and normoactive. Patient denies pain with palpation; no masses noted.

Sample Documentation of Unexpected Findings

The patient reports generalized abdominal pain, along with nausea and vomiting for the last two days. Abdomen is slightly distended. Bowel sounds hypoactive in all four quadrants. Pain reported at 7/10 and guarding noted with palpation of the RLQ. Dr. Smith notified at 0730.

This page titled 9.5: Sample Documentation was last modified on Mon, 28 Jun 2021 17:07:50 GMT and is shared under a CC BY-SA license and was authored, remixed, and/or curated by Valerie J. Bugosh, Leisa E. McAlicher, and Katherine Zaharchuk.

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Sample Documentation of Expected Findings

Sample Documentation of Unexpected Findings