For this patient we are going to record the physical examination as starting usually with their vital signs. What is their general appearance; their head, ears, eyes, nose, throat; neck; lymph nodes; chest; cardiac; abdominal; GI; skin; musculoskeletal; neurologic; and psychiatric? For reimbursement you have to do at least 5 systems, all right? In terms of Nursing 612, I want to see a complete note. I want you to do all of the systems in your review of systems and as many systems as possible in your physical exam. Obviously if you don't do that documentation or that exam in those systems that you don't record it, but you want to be as thorough as possible because you're learning how to document.
As you can see, if it is negative you don't put within normal limits are negative, you describe what is negative. So this person is well-developed. He is a white male. He has some mild ill appearance but he has no acute respiratory distress. Those are all general characteristics in a note for a physical exam. His head, eyes, ears, nose, and throat are pretty negative, but I'm describing what within normal limits and negative it is. Head is normocephalic, no scalper sinus tenderness. Conjunctivae are pink. No injection or jaundice. PERRLA. Ears, canals with mild cerumen present. Tympanic membrane pearly gray. Hearing is grossly intact (by just having a conversation with the patient) and what the nasopharynx looks like (pink and moist, posterior oropharynx without lesions or exudate). This is a negative HEENT assessment, but it is descriptive. It is not saying within normal limits. It is not saying anything for the patient. It is objective information so on and so forth that you can read on its own.
When you get to skin that is what is going to be positive indication that there is a rash, so everything in this documentation should match: your Chief Complaint (rash); History of Present Illness (should talk about the skin and a rash); and then in the Skin area there should be something to indicate that you are assessing the skin. This is a vesicular rash. It is raised. It is erythematous. It is linear. It is on the right side of the chest and it follows the dermatome. This is what you are seeing, touching, feeling, and hearing. That is what you record.