SAMPLE 1

75-year-old female appears to younger than her stated age AOX3. Adequately
groomed, no unusual body odor noted. Speech is clear. Responds appropriately to
touch and voice. Maintains eye contact. Affect cooperative and calm during the
assessment. Current diet status: thin liquid, aspiration risk. VS @ 0800 BP 142/64;
68 HR; 18 RR; 98.2 T; O2 Sat = 98% at room air. Pain level of 4/10 reported. Skin
color is appropriate to ethnicity, warm and dry. Turgor <3 seconds. No excess
perspiration. The cornea is clear and bright. Sclera white. No excessive tearing
noted. PERRL, 3 mm. Nostrils patent bilaterally. The ear is symmetrical, no
discharge observed. No visible lesions, edema and ecchymosis. Hearing intact;
able to answer questions without repeating. Lips and buccal mucosa pink without
lesions. Upper and lower teeth are intact. Breathing is unlabored. No accessory
muscles used and no pursed-lip breathing. The trachea is midline. Denies
tenderness over the ribs were other bony prominences. Normal vesicular sounds
auscultated over four lung lobes. S1 and S2 noted. Regular heart rate was noted.
Pacemaker in place. Soft, no distention on four quadrants. Normoactive bowel
sounds were auscultated on four quadrants. Voided 1 hour before the
assessment, stated no problem with voiding. Reported yellow-colored urine.
Clean fingernails with no clubbing. Radial pulse +3 regular and equal bilaterally.
Capillary refill <3 seconds. Grip strength equal bilat. LE, RE reported weakness. No
erythema, trace edema on LE. LT anterior abdominal surgery and lumbar surgery
incisions were assessed, no erythema, no ecchymosis, no exudate found at the
time of the assessment. Skin warm to touch. Dorsalis pedis pulse +2, equal
bilaterally. Capillary refill <3 seconds lower extremities. Patient walks clutching
onto furniture for support; is stooped but is able to lift the head while walking
and does not lose balance; steps are short.
SAMPLE 2

66-year-old male looks younger than stated age AOX3. Adequately groomed, no
unusual body odor noted. Speech is clear. Responds appropriately to touch and
voice. Maintains eye contact. Affect cooperative and lethargic during the
assessment. Current diet status: NPO. VS @ 0700 BP 114/62; 85 HR; 18 RR; 98.4 T;
O2 Sat = 98% at room air. Pain level of 6/10 reported. Skin color is appropriate to
ethnicity, warm and dry. Turgor >3 seconds. No excess perspiration. The cornea is
clear and bright. Sclera white. No excessive tearing noted. PERRL, 3 mm. Nostrils
patent bilaterally. The ear is symmetrical, no discharge observed. No visible
lesions, edema and ecchymosis. Hearing intact; able to answer questions without
repeating. Lips and buccal mucosa pink without lesions. Breathing is unlabored.
No accessory muscles used and no pursed-lip breathing. The trachea is midline.
Denies tenderness over the ribs were other bony prominences. Normal vesicular
sounds auscultated over four lung lobes. S1 and S2 noted. Regular heart rate was
noted. Pacemaker in place. Soft, mild distention on four quadrants. Normoactive
bowel sounds were auscultated on four quadrants. Wound bag manager in
midline abdomen. Yellow orange drainage was observed, the bag was foggy. Skin
below the bag showed minimal redness. Void 30 minutes before the assessment,
stated no problem with voiding. Reported yellow-colored urine. Clean fingernails
with no clubbing. Radial pulse +2 regular and equal bilaterally. Capillary refill <3
seconds. Grip strength equal bilaterally. Upper extremities with full range of
movement. No erythema or edema on upper and lower extremities. Skin warm to
touch. Dorsalis pedis pulse +2, equal bilaterally. Capillary refill <3 seconds lower
extremities with normal ROM. Turns self, can ambulate with assistance.