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avoid saying words like
normal and as expected
say words like
within defined limits and appropriate for circumstances
within defined limits you need to..
state what is in defined limits for what is expected for the patient
do you need to be more specific or less specific for a patient you see for the first time
more specific because you need to know the baseline and get to know patient
when charting always…
write down the floor that you are on because floors like ER onluy do focused assesments while others dont floors can vary with what you are doing