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Throat exam documentation 2025

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The document is a comprehensive checklist for conducting an eye, ear, nose, and throat (ENT) examination. It includes sections for patient information, vital signs, and detailed examination procedures for each area (eyes, ears, nose, throat), allowing the examiner to note normal findings or describe abnormalities. The form emphasizes the importance of clinical discretion and confidentiality.

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What is the normal description of throat?

The hollow, muscular tube inside the neck that starts behind the nose and ends at the top of the trachea (windpipe) and esophagus (the tube that goes to the stomach). The throat acts as a passageway for air to enter the lungs and food and liquid to enter the esophagus.

How do you document a normal throat assessment?

Throat/Mouth Oral mucosa is pink and moist with good dentition. Tongue normal in appearance without lesions and with good symmetrical movement. No buccal nodules or lesions are noted. The pharynx is normal in appearance without tonsillar swelling or exudates.

How do you describe a normal throat?

What does a normal throat look like A normal throat typically appears pink and smooth, with no signs of redness, swelling, or exudate. In a healthy individual, the throat should not cause any pain or discomfort during swallowing.

How do you describe a throat examination?

A throat and neck exam is an examination in which the doctor feels for swollen lymph nodes in the neck and looks down the throat with a small, long-handled mirror to check for abnormal areas.

What are the normal findings in the mouth and throat?

Mouth and Throat: Lips normal color, without lesions. Teeth present, good dental hygiene. Gums (or: gingiva) and mucous membranes pink without bleeding, lesions or inflammation. Tongue normal size and papillation, midline protrusion.

throat assessment documentation

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How do you describe throat symptoms?

Signs and symptoms might include: Pain or a scratchy sensation in the throat. Pain that worsens with swallowing or talking. Difficulty swallowing.

What is the medical examination of throat?

Direct laryngoscopy uses a tube called a laryngoscope. The instrument is placed in the back of your throat. The tube may be flexible or stiff. This procedure allows your provider to see deeper in the throat and to remove a foreign object or sample tissue for a biopsy.

Throat exam documentation 2025

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What is the normal description of throat?

How do you document a normal throat assessment?

How do you describe a normal throat?

How do you describe a throat examination?

What are the normal findings in the mouth and throat?

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How do you describe throat symptoms?

What is the medical examination of throat?

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