I combine a lot of templates, (IE: for a diabetic foot exam)
Feet: Bilateral exam reveals no open wounds, or skin breakdown. There is hair present all the way to the toes. The dorsalis pedis pulse is 2/4 and equal bilaterally. Monofilament testing reveals the patient to be neurologically intact with pinpoint discrimination all the way to the toes.
With editing that is typed IN ALL CAPS. We find this useful for several reasons. When I glance back at my note before signing the CAPS show I have edited the note, and when my Partner or I read each other notes, we can quickly find the pertinent parts:
Feet: Bilateral exam reveals ERYTHEMA AND MACERATION BETWEEN THE FOURTH AND FIFTH TOES ON THE RIGHT FOOT CONSISTENT WITH TINEA PEDIS. There is NO hair present all the way to the toes. The dorsalis pedis pulse is ONLY TRACE and equal bilaterally. Monofilament testing reveals the patient to be neurologically intact with pinpoint discrimination all the way to the toes.
