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Narrative Charting For Baseline Assessment

A&O x3 with clear speech and normal neurological exam including equal and strong bilateral extremity movement. Cardiac exam found normal heart sounds, rate, and rhythm with strong peripheral pulses. Lungs were clear to auscultation and patient denied cough. Abdomen was soft with normal bowel sounds and no pain on palpation. Foley catheter was draining clear amber urine. Skin was warm, dry, and intact.

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Mei Sarte
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494 views

Narrative Charting For Baseline Assessment

A&O x3 with clear speech and normal neurological exam including equal and strong bilateral extremity movement. Cardiac exam found normal heart sounds, rate, and rhythm with strong peripheral pulses. Lungs were clear to auscultation and patient denied cough. Abdomen was soft with normal bowel sounds and no pain on palpation. Foley catheter was draining clear amber urine. Skin was warm, dry, and intact.

Uploaded by

Mei Sarte
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Narrative Charting for Baseline Assessment (WHY IS YOUR PATIENT HERE?

(Neuro)

A&O x3. PERRL. Speech clear. Denies c/o pain (if patient is having pain, place
your assessment findings under the system involved). MAE X4 to command with
bilateral movement equal and strong. Morse fall scale
(Misc: if patient has recent hx of surgery or neuro event, check for
pronator drift, mid-line tongue extension, thrush [candida], etc.)

(Cardiac)

S1S2. RRR. 2+ peripheral pulses. Cap refill < 3 sec to BLE. RFA SL intact/patent
without redness @ insertion site.
(Misc: murmurs, pitting edema [write in after peripheral pulse
assessment], dialysis access, telemetry, etc.)

(Pulm) Bilateral breath sounds equal and unlabored. Post/ant fields clear to auscultation. Denies c/o
cough. (Misc: adventitious breath sounds, sputum, resp. distress, etc)

(GI) Normoactive BS X4 quadrants. No c/o pain/tenderness with gentle


palpation. Last BM (fill in the blank) & described/documented as (fill in the blank).
(Misc: NGT, G-J tube, N&V, etc.)

(GU) Foley to gravity drainage. Urine clear & amber colored. (Misc: abnormal colored urine,
abnormal urine output [too much or too little], difficulty voiding)

(Skin) Warm, dry, and intact. (Misc: wound care, inspection of skin folds), Braden scale score

Abbreviations: MAE (moves all extremities)


RRR (regular rate & rhythm)
BLE (bilateral lower extremities)
SL (saline lock)
BS (bowel sounds)

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