The pharynx is normal in appearance without tonsillar swelling or exudates. Tongue normal in appearance without lesions and with good symmetrical movement.
Throat/Mouth– Oral mucosa is pink and moist with good dentition. Hearing is intact with good acuity to whispered voice. The tympanic membrane is normal in appearance with a good cone of light.
The ear canal is clear without discharge. No signs of nystagmus.Įars – The pinna, tragus, and ear canal are non-tender and without swelling. Fundi appear normal including optic discs and vessels. Conjunctivae are clear without exudates or hemorrhage. Hair is of normal texture and evenly distributed.Įyes – Visual acuity is intact. Head – The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Nystagmus– Visual condition in which the eyes make repetitive and uncontrolled movements.ĭocumenting a normal exam of the head, eyes, ears, nose and throat should look something along the lines of the following:.Helpful for documenting an eye assessment. PERRLA – Shorthand for Pupils Equal, Round, React to Light, Accommodation.Entrapment of these muscles can occur, particularly with trauma, causing problems with ocular movement. These movements are controlled by a set of small muscles in the face. EOM ( Extraocular Movements) – Movement of the eye in all directions, up, down, right and left.Familiarize yourself with these terms as you perfect your exam and documentation technique. There are a few terms you may encounter in HEENT documentation that can be helpful to include in your own charts. While assessing additional items like sensation of the face are important, we have covered these in the documentation review of the neurological system. Palpation – Palpate for areas of tenderness or other abnormalities such as masses or lymphadenopathy.In the HEENT exam, inspection also includes visualization of the ear canals and tympanic membrane with an otoscope as well as the pharynx. Inspection – Assess the head and face for external abnormalities such as erythema in the presence of infection, or bruising and deformity in the event of trauma.Whether you’re doing a well child check up, or assessing a patient for an acute illness, as a nurse practitioner you’ll likely do your fair share of HEENT exams and must be familiar with the exam’s basic components. Today, let’s check out basic documentation of the HEENT (Head, Eyes, Ears, Nose, Throat) exam. These posts will help guide your charting giving you the words you may need to accurately represent a physical exam.
#TRANSNOMINO DOCUMENTATION SERIES#
To give you a feel for the skills you will develop in the ThriveAP virtual NP program we’ve been doing a system-by-system series on documentation. That is why charting is a key component in our transition to practice curriculum. Completing charts in a time efficient manner is no easy task, particularly early in your nurse practitioner career. You must also provide sufficient documentation so that you can justify your decision making should questions about the care you provided arise. You need to present your patient in a manner such that other providers can glance at the chart and pick up where you left off. If you’re a nurse practitioner new grad, documenting a patient encounter can be a bit of a struggle.
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