CHARTING SUGGESTIONS INCLUDING NORMAL FINDINGS
(NHC)
1. The chart notes for each visit should be comprehensive enough to give the pertinent info without always needing to refer to every past visit -- at least carry over from visit to visit the identifying data, current medications and supplements, complete problem/concerns list.
2. Begin every ROC chart note with a brief phrase of identifying data: for example, "F/u on sinus headache treatment," "F/u on irregular menses, acne, and food allergies." When presenting the case in preview or review this introduction should be a whole sentence such as, "This is a 40 year old woman who comes in for evaluation of abdominal pain of 3 days duration." "This is a 56 year old man being treated here for hypertension and stress management, here today for a 3 month follow up."
3. Physical Exam normal findings. These suggestions cover only the basics. Choose only what is appropriate/useful, and remember that we need to be more specific with pertinent negative findings when we are ruling something out.
General appearance: Well nourished, well developed, (for given age range), male or female, in no acute/mild/moderate/acute distress ("distress" could refer to pain, respiratory distress, mental agitation, etc.). Even when you don't do a PE, please note something about the general appearance.
Skin: warm and dry
Head: Normocephalic, atraumatic
Eyes: PERRLA (pupils equally round and reactive to light and accommodation), EOMI (extra-ocular movements intact) (or you could say EOM's full), nonicteric, fundi benign (or: discs flat, no hemorrhages or exudates).
Ears: TM's clear bilaterally
Oropharynx: mucous membranes pink and moist
Neck: supple, non-tender, no nodes, no thyromegaly, trachea midline
Lungs: lung fields clear to percussion and auscultation
Heart: S1, S2 regular, no murmurs, gallops or rubs
Abdomen: flat (or concave or obese, etc), non-tender, active bowel sounds, no lesions, masses or organomegaly (if you have measured the liver span, note that)
Neurologic: Cranial Nerves II-XII intact. Gait, speech normal. (please specifically describe any strength, sensation and cerebellar function testing you do) DTR's intact. (Do enumerate specific findings as appropriate)
Extremities: no cyanosis, clubbing or edema, peripheral pulses intact gynecological:vulva: skin pink, no lesions, inguinal nodes non palpable(NP), female hair pattern, no nits
(eggs from lice)or insects observed