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typhon template. quick guide/template for faster documentation, Transcriptions of Nursing

template for typhon clinic documentation

Typology: Transcriptions

2023/2024

Uploaded on 02/22/2025

rachel-claybrook
rachel-claybrook 🇺🇸

2 documents

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Constitutional symptoms:
Eyes: Denies blurred/double vision, myopia, and hyperopia. Denies eye
drainage. Denies floaters. Sclera is white with pink conjunctiva. No drainage
present. Cranial nerves 2, 3, 4, and 6 intact. Examination of the fundus
reveals bilateral pupillary dilation and no lesions. PERLA noted.
Ears: Denies tinnitus and vertigo. Denies drainage and pain. Denies changes
in hearing. No tenderness to auditory canal, cerumen is normal. Tympanic
membrane is intact, translucent, pearly grey in color. No tenderness to
pinnae and tragus. Cranial nerve 8 intact.
Nose: Denies drainage, recent nose bleeds or trauma. Denies sinus
pain/pressure. Denies nasal obstruction due to deviated septum. Septum is
midline with no deviation. Turbinates are pink, moist and non-edematous.
Nares are patent and without obstruction.
Mouth: Denies lesions, thrush, broken teeth, and dental pain. Tongue is pink
and moist without lesions. No broken teeth or dental caries noted. Tongue
is midline without fasciculations, cranial nerve 12 intact.
Throat: Denies throat pain and difficulty swallowing. Denies changes in
voice. Tonsils are 2+ without erythema and exudate.
Neck: Denies neck pain and tenderness. Denies injuries to neck. No
lymphadenopathy upon palpation. Trachea is midline without deviation. No
signs of thyroid enlargement. Full cervical ROM noted. Cranial nerve 11
intact. Neck is supple without signs of goiter.
Cardiovascular/Peripheral vascular: Denies chest pain, palpitations, DOE,
orthopnea. Denies discoloration to hands and feet. Denies claudication. S1,
S2 heard on auscultation. Regular rate and rhythm noted. No gallops or
murmurs.
Respiratory: Denies SOB, hemoptysis, and pain while inhaling/exhaling.
Lung sounds clear throughout all lobes to anterior and posterior aspect.
Respirations are even and unlabored.
GI/GU/Reproductive: Denies abdominal pain, pelvic pain, vaginal bleeding,
dysuria, urgency, and frequency. Denies flank pain, n/v/d. Denies changes in
stool and urination. No CVA or suprapubic tenderness. Negative Cullen sign.
No guarding or grimacing on palpation. Bowel sounds present in all four
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 Constitutional symptoms:  Eyes: Denies blurred/double vision, myopia, and hyperopia. Denies eye drainage. Denies floaters. Sclera is white with pink conjunctiva. No drainage present. Cranial nerves 2, 3, 4, and 6 intact. Examination of the fundus reveals bilateral pupillary dilation and no lesions. PERLA noted.  Ears: Denies tinnitus and vertigo. Denies drainage and pain. Denies changes in hearing. No tenderness to auditory canal, cerumen is normal. Tympanic membrane is intact, translucent, pearly grey in color. No tenderness to pinnae and tragus. Cranial nerve 8 intact.  Nose: Denies drainage, recent nose bleeds or trauma. Denies sinus pain/pressure. Denies nasal obstruction due to deviated septum. Septum is midline with no deviation. Turbinates are pink, moist and non-edematous. Nares are patent and without obstruction.  Mouth: Denies lesions, thrush, broken teeth, and dental pain. Tongue is pink and moist without lesions. No broken teeth or dental caries noted. Tongue is midline without fasciculations, cranial nerve 12 intact.  Throat: Denies throat pain and difficulty swallowing. Denies changes in voice. Tonsils are 2+ without erythema and exudate.  Neck: Denies neck pain and tenderness. Denies injuries to neck. No lymphadenopathy upon palpation. Trachea is midline without deviation. No signs of thyroid enlargement. Full cervical ROM noted. Cranial nerve 11 intact. Neck is supple without signs of goiter.  Cardiovascular/Peripheral vascular: Denies chest pain, palpitations, DOE, orthopnea. Denies discoloration to hands and feet. Denies claudication. S1, S2 heard on auscultation. Regular rate and rhythm noted. No gallops or murmurs.  Respiratory: Denies SOB, hemoptysis, and pain while inhaling/exhaling. Lung sounds clear throughout all lobes to anterior and posterior aspect. Respirations are even and unlabored.  GI/GU/Reproductive: Denies abdominal pain, pelvic pain, vaginal bleeding, dysuria, urgency, and frequency. Denies flank pain, n/v/d. Denies changes in stool and urination. No CVA or suprapubic tenderness. Negative Cullen sign. No guarding or grimacing on palpation. Bowel sounds present in all four

quadrants with normoactive bowel sounds. Abdomen is flat, soft and non- tender.  Musculoskeletal: Denies joint pain, swelling, limited ROM. Denies muscle cramps, weakness, and stiffness. Denies difficulty with ambulation. No deformities noted. ROM noted. Able to ambulate without assistance.  Neurological: Denies weakness, tremors, numbness, and tingling. Denies changes in speech and coordination. Alert and oriented, answers questions appropriately for developmental age. Denies headache and fever.  Integumentary: Denies abnormal hair distribution, lesions, rashes and hives. No present wounds noted. No signs of tenting or edema. Skin is warm, dry, and intact.  Psychiatric: Denies suicidal ideation, homicidal ideation, anxiety, and depression. Denies visual, auditory and command hallucinations