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PAGE 1
EHR Expert Chart
DOB: 34.0 Years before start Attending: Michael Smertka,
Timothy Lee (M)
(34 yoa) MD
MRN: 931079
Height: 70 in Code Status: Full code
Allergies: Sulfa
Weight: 165 lb Comments: Annual physical
Assessment
Head, Face, Neck
Head round and symmetrical, Normocephalic,
Head, Face
Symmetrical facial features
Neck
Comment
Eyes, Ears, Nose,
Throat
Eyes Symmetrical
Eyes Comments Sclerae white.
Ears Symmetrical placement
Ears Comments
Nose, Throat
Nose, Throat Comments
Neurological group
Level of Consciousness Full consciousness
Orientation Oriented x 4
Cognitive WDL
Speech Clear
Pupil Response Bilateral pupils reactive
Pupil size (mm) left 5 mm right 5 mm
Deep Tendon Reflexes
Alert and responsive. Speech clear and appropriate
Neurological Comments to topic. Pupils equal and constrict to 3 mm
bilaterally when assessing reactivity to light.
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EHR EXPERT CHART
Glasgow Coma Scale
Best Eye Response
Best Verbal Response
Best Motor Response
Glasgow Total
Respiratory
, Resp. Effort/Pattern WDL – Regular rhythm, bilaterally even and unlabored
Respirations even and unlabored at a rate of 16
breaths/min.
Breath Sound, Comments Lungs clear to auscultation in all fields bilaterally anteriorly
and posteriorly. Chest wall movement symmetrical with
inspiration and expiration anteriorly and posteriorly.
Cough None
Sputum
Resp. Interventions
Intervention, Comments
Respiratory Airways/Drains
Airway/Drain, Comments
Oxygen Source Room Air
Oxygen rate and comments Respirations 16 breaths/min.
Cardiac
Cardiac Rhythm/Sounds WDL - Regular rhythm, normal rate, S1 and S2 present
Cardiac Symptoms
Monitors/Telemetry?
Cardiac Comments S1, S2 noted. Apical pulse regular with a rate of 64/min.
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EHR EXPERT CHART
Peripheral Vascular
Capillary refill is less than 3 sec, pulse is palpable
RUE
and strong, +3 – strong pulse
Capillary refill is less than 3 sec, pulse is palpable
LUE
and strong, +3 – strong pulse
Capillary refill is less than 3 sec, pulse is palpable
RLE
and strong, +3 – strong pulse
Capillary refill is less than 3 sec, pulse is palpable
LLE
and strong, +3 – strong pulse
Capillary refill to all extremities 2 seconds. Radial and
Periph. Vasc. Comments dorsalis
pedis pulses palpable and 3+ bilaterally. Rhythm regular.
Integumentary
Skin Color Appropriate for ethnicity, even distribution
Skin Temperature/Condition Warm
Skin Turgor Recoils immediately
Skin intact throughout with no lesions or masses
Skin Comments
noted. Skin warm to touch throughout.
Braden Scale
Sensory perception
Moisture
PAGE 1
EHR Expert Chart
DOB: 34.0 Years before start Attending: Michael Smertka,
Timothy Lee (M)
(34 yoa) MD
MRN: 931079
Height: 70 in Code Status: Full code
Allergies: Sulfa
Weight: 165 lb Comments: Annual physical
Assessment
Head, Face, Neck
Head round and symmetrical, Normocephalic,
Head, Face
Symmetrical facial features
Neck
Comment
Eyes, Ears, Nose,
Throat
Eyes Symmetrical
Eyes Comments Sclerae white.
Ears Symmetrical placement
Ears Comments
Nose, Throat
Nose, Throat Comments
Neurological group
Level of Consciousness Full consciousness
Orientation Oriented x 4
Cognitive WDL
Speech Clear
Pupil Response Bilateral pupils reactive
Pupil size (mm) left 5 mm right 5 mm
Deep Tendon Reflexes
Alert and responsive. Speech clear and appropriate
Neurological Comments to topic. Pupils equal and constrict to 3 mm
bilaterally when assessing reactivity to light.
www.atitesting.com ©2019 Assessment Technologies Institute ®, Inc.
PAGE 2
EHR EXPERT CHART
Glasgow Coma Scale
Best Eye Response
Best Verbal Response
Best Motor Response
Glasgow Total
Respiratory
, Resp. Effort/Pattern WDL – Regular rhythm, bilaterally even and unlabored
Respirations even and unlabored at a rate of 16
breaths/min.
Breath Sound, Comments Lungs clear to auscultation in all fields bilaterally anteriorly
and posteriorly. Chest wall movement symmetrical with
inspiration and expiration anteriorly and posteriorly.
Cough None
Sputum
Resp. Interventions
Intervention, Comments
Respiratory Airways/Drains
Airway/Drain, Comments
Oxygen Source Room Air
Oxygen rate and comments Respirations 16 breaths/min.
Cardiac
Cardiac Rhythm/Sounds WDL - Regular rhythm, normal rate, S1 and S2 present
Cardiac Symptoms
Monitors/Telemetry?
Cardiac Comments S1, S2 noted. Apical pulse regular with a rate of 64/min.
www.atitesting.com ©2019 Assessment Technologies Institute ®, Inc.
PAGE 3
EHR EXPERT CHART
Peripheral Vascular
Capillary refill is less than 3 sec, pulse is palpable
RUE
and strong, +3 – strong pulse
Capillary refill is less than 3 sec, pulse is palpable
LUE
and strong, +3 – strong pulse
Capillary refill is less than 3 sec, pulse is palpable
RLE
and strong, +3 – strong pulse
Capillary refill is less than 3 sec, pulse is palpable
LLE
and strong, +3 – strong pulse
Capillary refill to all extremities 2 seconds. Radial and
Periph. Vasc. Comments dorsalis
pedis pulses palpable and 3+ bilaterally. Rhythm regular.
Integumentary
Skin Color Appropriate for ethnicity, even distribution
Skin Temperature/Condition Warm
Skin Turgor Recoils immediately
Skin intact throughout with no lesions or masses
Skin Comments
noted. Skin warm to touch throughout.
Braden Scale
Sensory perception
Moisture
