When documenting patient information, phrases like 'Lung sounds diminished with crackles to right upper lobe' should be avoided, while 'Oriented person, place, and time' and 'Vital signs within normal limits' are suitable for accurate documentation.
Lung sounds diminished with crackles to right upper lobe: This phrase should not be used when documenting as it indicates abnormal findings in the patient's lung examination. Crackles are abnormal respiratory sounds often heard in conditions like pneumonia.
Oriented person, place, and time: This phrase is appropriate and indicates that the patient is aware of their surroundings and situation, demonstrating normal mental status.
Vital signs within normal limits: This phrase is positive and shows that the patient's vital signs are within the expected healthy range, reflecting overall good health.
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