9.5: Sample Documentation
selected template will load here
This action is not available.
The patient denies abdominal pain, nausea, vomiting, bloating, constipation, diarrhea, urinary pain, urgency or frequency, change in appetite, food intolerance, dysphagia, or personal or family history. Abdominal contour is flat and symmetric. No visible lesions, pulsations, or peristalsis noted. Bowel sounds present and normoactive. Patient denies pain with palpation; no masses noted.
The patient reports generalized abdominal pain, along with nausea and vomiting for the last two days. Abdomen is slightly distended. Bowel sounds hypoactive in all four quadrants. Pain reported at 7/10 and guarding noted with palpation of the RLQ. Dr. Smith notified at 0730.