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Skin and HEENT documentation example - Cassi Foster...

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Cassi FosterDocumentation Skin, Hair, Nails, and HEENT:Skin: Smooth, soft, pink, warm, dry and intact with turgor less than 2 seconds.Approximate 2cm bruises on anterior LE bilaterally.No cyanosis, pallor or jaundice noted.Hair: Brown, shiny, thick, soft in texture with even distribution, no lesions noted on the scalp.Nails:Nail beds pink, smooth evenly rounded with even distribution and well groomed upperand lower extremities bilaterally with no evidence of clubbing or lesions noted.Head and neck:Normocephalic, scalp intact, face symmetrical bilaterally.No JVD notedbilaterally, full ROM of neck. Trachea midline. No masses. Lymph nodes bilaterally enlarged,approximately 2 cm, moveable, and tender to the touch.Eyes:Symmetrical bilaterally, pupil size 2.
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Fall
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hard palate, soft palate, palate, Cassi Foster

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