Use when the nasal airway is patent, there is no active bleeding, and the cannula skin is intact. 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 nasal and sinus assessment completed. Nares patent bilaterally without obstruction; [no] epistaxis; drainage [absent/clear]; no sinus tenderness or facial pain. Skin under and around the nasal cannula intact — nares, columella, and behind the ears — without pressure marks, at [flow] L/min. Smell at baseline; mucosa moist with [humidification]. Anticoagulant [agent] and blood pressure [value] noted where relevant. The patency and — given continuous oxygen — the cannula-skin surveillance against baseline confirm no bleeding or breakdown and continued appropriateness of the plan; epistaxis control, cannula skin care, and humidification were reinforced with the patient/caregiver, who [teach-back result] (cross-reference Respiratory/COPD, Anticoagulation).
Short form
Skilled nasal/sinus assessment: nares patent; no epistaxis; no sinus tenderness; cannula skin intact (nares/columella/ears) at [flow]; smell at baseline; mucosa moist. Plan continued. Epistaxis-control and cannula skin-care teaching reinforced, teach-back correct.
