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Old 04-11-2013
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Question I didn't write VS in PN !

Hello guys,

I didn't write vital signs in all patient notes .. All was normal but I didn't write it in PN .. Is it big problem?
Also, in most of cases I wrote HEENT: mouth and pharynx WNL , is that ok?
My form in every PE:
HEENT: mouth, pharynx and eye WNL
Neck: supple, no lymphadenopathy and normal thyroid
Chest: clear breath sounds bilaterally (if chest case, I mentioned tactil fremitous, tenderness and wheezes)
Heart: RRR, normal s1 and s2 and no murmurs,rubs or gallops
Abdomen: soft, not tender, +bs, no distenstion and no organomegaly
If neuro : dtrs +2 through out. Sensations: intact. Cranial nerves: 2-12 intact. Strenoth: 5/5 in all muscle groups

This was my PN in most of cases and I just changed if any abnormalities
Do you think it is good ?

I'm still in post-cs exam shock

Last edited by HRK2011; 04-11-2013 at 09:17 PM.
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