: This client is a 23-year-old white female complaining of a painful, swollen ankle. States that she stepped ‘funny’ off a step two days ago and thinks she heard a ripping sound. She takes no...

: This client is a 23-year-old white female complaining of a painful, swollen ankle. States that she stepped ‘funny’ off a step two days ago and thinks she heard a ripping sound. She takes no medications and has no allergies. The client reports pain as 5/10 with sharp twinges when trying to walk, a notable limp is noted when the client walks favoring the affected extremity. She states resting and ice decreases pain to 2/10 aching. Pain is primarily in the outer aspect of ankle and foot. Has no prior injury to this area. No significant past medical history.” When you examine the ankle the outer aspect of the malleolus is swollen and reddened with 2+ edema noted to the area, pedal pulses are palpable and strong.

In terms of your objective findings, remember to
only record what you have assessed
.
Do not make a diagnosis or state the cause of a particular finding. You are not coming to any conclusions within your documentation. You are simply documenting subjective and objective findings. When your documentation is complete, you will note any findings that were abnormal.

what You will document your subjective and objective findings,