The end of my first semester is quickly approaching and our "final" is to perform and document a physical assessment (we bring our own patient). I can find all sorts of videos and help on HOW TO perform the assessment, but tips and hints about how to properly DOCUMENT are sorely lacking. I know, for example, that nothing is "normal" but should be documentated as "within normal limits" or as "without abnormalities" but anyone have any sites or tips for properly documenting NORMAL findings? Thanks!

You should have had a practicum on doing a physical assessment.
you want to start from the head and work your way down to the feet.
examples i was taught in this level 2 of LPN condensed course is start with neuro, then cardio, then resp, gastrointestinal, genitourinary, skin, musculoskeletal, and other (IV)
ex to write assessment. Pt AAOx3, pupils perrl, speech is clear, denies any pain.
apical pulse rate regular, cap refill >3, pedal pulses palpable, no edema.
B/L breathe sounds clear, unlabored on RA SPo2 100%.
abd soft, non-distended, bsx4, denies any pain
continent clear yellow urine.
skin is warm, moist, fleshtone and intact.

hope this helps
Michele

Hey, we use a book by Jarvis that is extremely useful for documentation. Its small like a pocket book, but has all of the pertinant information that you need. I believe its called Physical Examination or something like that ( its in my car and I'm too cold to go outside right now ). I highly recommend any student to use this book. I will check back later with the title of the book.