12.4 Trial Documentation

Sample Documentation of Expected Findings

That patient denies abdominal pain, nausea, vomiting, bloating, constipation, diarrhea, urinary pain, urgency or frequency, change in appetite, foods intolerance, dysphagia, either personal or family history. Intestinal contour is flat and bottom. None visible lesions, beats, or peristalsis noted. Bowel sounds presentation and normoactive. Patient denies pain with palpation; no masses noted.

Sample Documentation of Unexpected Findings

The patient reports generalized belly pain, to with nausea and vomiting for of last two daily. Abdomen is slightly distended. Bowel sounds hypoactive included all four fourths. Pain reported among 7/10 and guarding noted is palpation of the RLQ. Dr. Metalworker notified at 0730.