10.5: Sample Documentation
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Patient reports no previous history for bone trauma, disease, infection, injury, or deformity. No symptoms of joint stiffness, pain, swelling, limited function, or muscle weakness. Patient is able to perform and manage regular daily activities without limitations and reports consistent exercise consisting of walking 2 miles for 5 days a week. Joints and muscles are symmetrical bilaterally. No swelling, deformity, masses, or redness upon inspection. Nontender palpation of joints without crepitus. Full ROM of the arms and legs with smooth movement. Upper and lower extremity strength is rated at 5 out of 5. Patient is able to maintain full resistance of muscle without tenderness or discomfort.
Patient reports “I felt a pop in my right ankle while playing basketball this afternoon” and “My right ankle hurts when trying to walk on it.” Pain is constant and worsens with weight-bearing. Patient rates pain at 4/10 at rest and 9/10 with walking and describes pain as an “aching, burning feeling.” Ibuprofen and ice decrease pain. Right ankle is moderately swollen laterally and anteriorly with tenderness to palpation but no erythema, warmth, or obvious deformity. Color, motion, and sensation are intact distal to the ankle. ROM of the right ankle is limited and produces moderate pain. Minimal eversion and inversion demonstrated. Patient is unable to bear weight on the right ankle. Dr. Smith notified and an order for an ankle X-ray received. The right ankle was elevated and ice applied while the patient waits for the X-ray.