Student Documentation Model Documentation


Document: Vitals Document: Provider Notes

Student Documentation Model Documentation


Alert and oriented x3: Some discomfort due to abdominal pain HEENT: moist mucus mambrane, normal skin turgor, no tenting Heart: S1 and S2 with no abnormal heart sounds Lungs; CTA Liver: 1cm below Rt costal margin: nontender Abdomen: BS present at all quads, normoactive, No bruits or friction sounds. Dullness on LLQ, Tender to touch, with guarding and distension. 2x4cm oblong mass palpated on LLQ. RUQ : with scar s/p choleystectomy, and al lower transverse abdominal scar from s/p cs no CVA tenderness Pelvic: neg Rectal: no hemorrhoids, strong spincter reflex, fecal mass detected in rectal vault Extremties: no edema: normal reflexes UA: clear but dark urine, neg for nitrites, wbc or ketones.

• General Survey: Uncomfortable and flushed appearing elderly woman seated on exam table grimacing at times. Appears stable mildly distressed. • HEENT: Mucus membranes are moist. Normal skin turgor; no tenting. • Cardiovascular: S1, S2, no murmurs, gallops or rubs; no S3, S4 rubs. No lower extremity edema. • Respiratory: Respirations quiet and unlabored, able to speak in sentences. Breath sounds clear to auscultation. • Abdominal: 6 cm scar in RUQ and 10 cm scar at midline in suprapubic region. An abdominal exam reveals no discoloration; normoactive bowel sounds in all quadrants; no bruits; no friction sounds over spleen or liver; tympany presides with scattered dullness over LLQ; abdomen soft in all quadrants; an oblong ma noted in the LLQ with mild guarding, distension; no organomega no CVA tenderness; liver span 7 cm @ MCL; no hernias. • Rectal: No hemorrhoids, no fissures or ulceration; strong sphinc tone, fecal mass in rectal vault. • Pelvic: No inflammation or irritation of vulva, abnormal discharg or bleeding; no masses, growths, or tenderness upon palpation. • Urinalysis: Urine clear, dark yellow, normal odor. No nitrites, WB RBCs, or ketones detected; pH 6.5, SG 1.017.

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