Use when the structural exam is unremarkable and surveillance is reassuring. 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 head and scalp assessment completed. Scalp intact without lesions, lacerations, or infestation; skull nontender without masses or step-offs; face grossly symmetric. [After the reported strike on …, serial neuro check unchanged from … with no evolving sign of intracranial injury.] Headache [absent / at chronic baseline, controlled], without red-flag features; temporal arteries nontender without jaw claudication or visual change. Mentation at the cognitive baseline; anticoagulation [agent] noted. The structural exam and — where applicable — the post-strike surveillance against the prior check confirm no evolving intracranial process and continued appropriateness of the plan; head-injury precautions and the signs to report were reinforced with the patient/caregiver, who [teach-back result] (cross-reference Neurological, Cognitive, Anticoagulation).
Short form
Skilled head/scalp assessment: scalp intact, skull nontender, face symmetric; [post-strike neuro check unchanged, no evolving sign]; no red-flag headache; temporal arteries nontender; mentation at baseline. Plan continued. Head-injury precautions reinforced, teach-back correct (see Neurological/Anticoagulation).
