Head to Toe Documentation 201

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 History
a. Demographics
b. Name of source
c. Reliability of source
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d. Chief complaint (use patient’s own words)

e. Symptom analysis
i.Time intervals and duration
ii.Changes in symptoms
iii.Character and quality of pain
iv.Association with other events
v.Attempted treatments prior to arrival
vi.Does it interfere with ADL’s
vii.Medications that the patient is currently taking.
2. Past Medical History
a. Previous hospitalizations
b. Previous surgeries
c. Major illnesses
d. Allergies
e. Family history
f. Personal history
i.Health risk factors
ii.Living conditions
iii.Suspected abuse and home safety
iv.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. Integumentary
b. Head
c. Eyes
d. Ears
e. Nose
f. Mouth
g. Throat
h. Neck
i. Chest
j. Breast
k. Heart
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l. Peripheral vascular system

m.Lungs
n. Abdomen
o. Genital
p. Rectum
q. Lymphatic
r. Musculoskeletal
s. Neurological
4. Health Assessment
a. General Survey
b. Measurement / vital signs
c. Integumentary
i.Any signs of rashes, lesions, ecchymosis,
discolorations
d. 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. Ears
i.Note any skin discolorations and any tenderness
upon movement of the pinna.
ii.Note any difficulty with hearing.
g. Nose
i.Is the nose midline?
ii.Are the nostrils patent?
iii.Any pain on palpation of the sinuses?
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h. Mouth
i.Inspect lips for color, moisture, cracking, or
lesions.
ii.Inspect tongue for color and moisture and to see if
the tongue is midline.
i. Throat
i.Check for a gag reflex.
ii.Assess tonsils and color of throat.
j. Neck
i.Assess pulses and trachea
k. 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 system
i.Assess the temperature of the extremities
bilaterally
ii.Assess the pulses of the extremities bilaterally
iii.Note any discolorations or wounds
iv.Note any edema that is present
n. Lungs
i.Assess the lung sounds for one full respiration and
exhalation.
ii.Note any adventious sounds
iii.Note any SOB or difficulty breathing
o. Abdomen
i.Inspect for shape and symmetry
ii.Percuss the abdomen
iii.Assess the bowel sounds in all four quadrants
p. Genitals
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i.Note any drainage, discolorations, abnormal

growths or wounds
q. Musculoskeletal
i.Assess ROM. Note any pain, tenderness, or
crepitation
ii.Assess the strength of the muscles bilaterally.
Note any weakness.
r. Neurological
i.Assess the cranial nerves
ii.Assess the reflexes
iii.Assess for hand grasp bilaterally
iv.Assess the push/pulls of the feet bilaterally.