Use when there is no new concerning adenopathy, an at-risk limb is protected, and any lymphedema is stable. Fill the bracketed blanks with the visit’s actual findings; the clinical findings are not changed — the reasoning a layperson cannot supply is added. The skilled rationale supports the record when it is accurate, individualized, consistent with the plan of care, and tied to the findings, orders, and patient response documented during the actual visit.
Skilled lymphatic assessment completed. No new lymphadenopathy; [chronic node unchanged]. [At-risk limb: girth …, unchanged from …; no new skin break; no streaking, warmth, or systemic signs.] Limb girth [stable/symmetric]; no lymphedema skin change beyond baseline; no breakdown. Compression [garment/bandage] fitted, worn as ordered, and effective, with intact skin beneath. The node assessment and at-risk-limb and lymphedema surveillance against baseline confirm no new infection or progression and continued appropriateness of the plan; limb precautions, compression use, and infection signs were reinforced with the patient/caregiver, who [teach-back result] (cross-reference Integumentary, Peripheral Vascular).
Short form
Skilled lymphatic assessment: no new adenopathy; at-risk limb girth unchanged, no streaking/infection; lymphedema stable; compression worn, effective, skin intact. Plan continued. Limb-precaution/compression/infection teaching reinforced, teach-back correct.
