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18 Feb 2012 Physical Assessment There's a full and symmetric expansion and the thumbs separate 2-3 cm during Nursing Assessment in Tabular Form General physical examination: The patient CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. A complete assessment is not necessarily carried out each time. (not necessarily including everything presented here) and document it on the admission form. The links below are to actual H&Ps written by UNC students during their inpatient clerkship rotations. The students have granted permission to have these H&Ps Example of a Complete History and Physical Write-up. Patient Name: Reports dysuria in the 3 days prior to hospitalization. No fever, no Physical Exam. 1. 24 Oct 2013 CHARTING EXAMPLES FOR PHYSICAL ASSESSMENT SKIN, HAIR AND NAILS Skin pink, Nails form 160 degree angle at base, are hard, smooth, and immobile. Has smooth, controlled, full range of motion of neck. Medicine History & Physical Assessment . working full time during the day. She reports she has been having trouble with her balance for the last few months. Sample Written History and Physical Examination. History and Physical Examination. Comments. Patient Name: Rogers, Pamela. Date: 6/2/04. Referral Source:. EXAMPLE OF A COMPLETE DOCUMENTATION. OF THE HISTORY AND PHYSICAL EXAMINATION. J.S. is a 30-year-old male who complains of “a bad sore 28 Jan 2013 DATA BASE SAMPLE: PHYSICAL EXAMINATION. WITH ALL NORMAL FINDINGS. GENERAL APPEARANCE: (include general mental status).
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