Head to Toe Documentation 2010

What is documentation?

1. Documentation provides baseline information about your patient.2. Documentation provides a source of communication to provide

coordinated care among healthcare providers.3. Documentation is a legal document.4. Documentation must be done legibly, accurately, and completely in a

timely manner.

Important things to remember when documenting in a chart…

1. You must use anatomical landmarks when describing locations.2. You must date and time the entry.3. You must sign the entry with your full name and licensure (J. Doe SN, NDC)4. You must use correct medical terminology and use correct spelling.5. You should document safety interventions that were completed (head of

bed elevated 45 degrees, side rails up times 2, patient repositioned on right side with heels elevated on pillows)

6. Always document any time the patient leaves the floor, returns from the floor, you assess the patient for a complaint, and when you leave the care of the patient to another nurse.

What do I document?

1. Personal Historya. Demographicsb. Name of sourcec. Reliability of sourced. Chief complaint (use patient’s own words)e. Symptom analysis

i. Time intervals and durationii. Changes in symptoms

iii. Character and quality of painiv. Association with other eventsv. Attempted treatments prior to arrival

Head to Toe Documentation 2010

vi. Does it interfere with ADL’svii. Medications that the patient is currently taking.

2. Past Medical Historya. Previous hospitalizationsb. Previous surgeriesc. Major illnessesd. Allergiese. Family historyf. Personal history

i. Health risk factorsii. Living conditions

iii. Suspected abuse and home safetyiv. Personal habits that affect health status

3. Review of Systems (Does the patient have any complaints or previous history with any of the systems)

a. Integumentaryb. Headc. Eyesd. Earse. Nosef. Mouthg. Throath. Necki. Chestj. Breastk. Heartl. Peripheral vascular systemm. Lungsn. Abdomeno. Genitalp. Rectumq. Lymphatic

Head to Toe Documentation 2010

r. Musculoskeletals. Neurological

4. Health Assessmenta. General Surveyb. Measurement / vital signsc. Integumentary

i. Any signs of rashes, lesions, ecchymosis, discolorationsd. Head

i. Is the skull symmetrical and smooth?ii. Any tenderness?

iii. Is the facial expression appropriate and is the face symmetrical?

iv. Are there any involuntary movements?e. Eyes

i. Are the conjunctiva and sclera normal? Note any abnormal color or drainage.

ii. Note the size, shape, and equality of the pupils and the pupilary light reflex and accommodation.

f. Earsi. Note any skin discolorations and any tenderness upon

movement of the pinna.ii. Note any difficulty with hearing.

g. Nosei. Is the nose midline?

ii. Are the nostrils patent?iii. Any pain on palpation of the sinuses?

h. Mouthi. Inspect lips for color, moisture, cracking, or lesions.

ii. Inspect tongue for color and moisture and to see if the tongue is midline.

i. Throati. Check for a gag reflex.

Head to Toe Documentation 2010

ii. Assess tonsils and color of throat.j. Neck

i. Assess pulses and tracheak. Chest

i. Note the shape and configuration of the chest wall. l. Heart

i. Auscultation of the aortic, pulmonic, tricuspid, and mitral areas with bell and diaphragm of the stethoscope.

m. Peripheral vascular systemi. Assess the temperature of the extremities bilaterally

ii. Assess the pulses of the extremities bilaterallyiii. Note any discolorations or woundsiv. Note any edema that is present

n. Lungsi. Assess the lung sounds for one full respiration and exhalation.

ii. Note any adventious soundsiii. Note any SOB or difficulty breathing

o. Abdomeni. Inspect for shape and symmetry

ii. Percuss the abdomeniii. Assess the bowel sounds in all four quadrants

p. Genitalsi. Note any drainage, discolorations, abnormal growths or

woundsq. Musculoskeletal

i. Assess ROM. Note any pain, tenderness, or crepitationii. Assess the strength of the muscles bilaterally. Note any

weakness.r. Neurological

i. Assess the cranial nervesii. Assess the reflexes

iii. Assess for hand grasp bilaterally

Head to Toe Documentation 2010

iv. Assess the push/pulls of the feet bilaterally.