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Chapter 14

DOCUMENTATION

The following is sample documentation of findings from physical assessment of the ears, nose, mouth, and

throat of a healthy adult.

Nurses Notes:

Subjective Data:

Denies problems with hearing, breathing, taste, swallow, teeth, or throat. No family history

of disease of ear, nose, mouth, or throat. Last dental examination 6 months ago. Has all

teeth. Last hearing test many years ago, no problems at that time. Has had “runny nose and

sore throat” associated with colds about once every winter. Takes aspirin for occasional

headache, no other medications. No medication, food, or environmental allergies.

Objective Data:

Responds to questions and instructions. Ears symmetrical in size, shape, configuration, no lesions. Mea-

tus patent, no discharge. Tragus mobile, nontender. Mastoid free of lesions, nontender. Otoscopic exami-

nation reveals small amounts of cerumen, canal clear, tympanic membrane gray and without lesions.

Whisper test reveals bilateral equal hearing. Rinne test AC > BC bilateral. Weber test reveals no lateral-

ization. Romberg—maintains balance. Nares patent, sinuses nontender, system midline, no lesions, mem-

branes moist, pink. Lips pink, moist, symmetrical. 28 teeth white, clean, intact. Tongue mobile, pink papillae

present, no lesions. Mucosa pink, moist, intact, Wharton’s and Stensen’s ducts patent. Uvula and soft

palate rise with “ah.” Pharynx, uvula, tonsils pink, moist, without lesions.

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