Which documentation is appropriate after assessing head, neck, and lymphatics?
1. Occasional headaches relieved by acetaminophen. No history of injury, seizure, tremor, dizziness. No neck swelling.
2. Denies hearing problems, never had specific exam. Nose patent, no injury, sense of smell intact, clear drainage with cold. No trouble eating or swallowing. Dental exam annually, last exam one month ago. Brushes and flosses twice daily.
3. Denies problems. "My bowels move every day with no problem. I get diarrhea when I'm nervous sometimes." Active bowel sounds present in all quadrants. Abdomen soft and non-tender to palpation.
4. Denies problems. No history of UTI. I pass urine five or six times a day and more if I drink more.
Correct Answer: 1
"Occasional headaches relieved by acetaminophen. No history of injury, seizure, tremor, dizziness. No neck swelling." is appropriate documentation when assessing head, neck and lymphatics. The other pieces of documentation are appropriate for other body systems.
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