Document only what you carefully examine and only the things that are pertinent. Ex Pt is alert and oriented x 3, with alcohol noted on breath. Exam is essentially normal, ENT clear with mildly dry mucus membranes. Lungs are clear. Abdomen soft nontender, neg. rebound.
Normal bowel sounds.
STAT laboratory and X-ray results may be important in making the diagnosis. This is where you think through the results of the history and physical examination. PLAN Further diagnostic studies needed. Therapeutic regimen including medications given, treatments prescribed. Specify dosage, how they are to be taken, and how often.