Documenting HEENT Assessments: Examples and Tips

Accurate and thorough documentation is a cornerstone of quality patient care. For nurses and healthcare providers, knowing how to document a HEENT assessment —Head, Eyes, Ears, Nose, and Throat—is essential for tracking changes in a patient’s condition, communicating with other providers, and ensuring continuity of care.

In this post, we’ll walk through how to effectively document HEENT findings , including examples of normal and abnormal documentation , key phrases to use, and helpful tips to make your charting clear, concise, and compliant .

📝 What Is HEENT Documentation?

HEENT documentation refers to the written record of findings from the head-to-neck physical examination . This includes observations about the patient’s head shape, eyes, pupils, vision, ears, hearing, nose, sinuses, mouth, throat, and neck structures.

It is often part of:

Initial patient assessments
Routine wellness exams
Follow-up visits for ENT-related complaints
Pre-op or post-op evaluations

🧾 Components of a HEENT Assessment

Before diving into documentation, let’s briefly review what each section involves:

Section	What You Assess
Head	Shape, symmetry, trauma, swelling
Eyes	Vision, eye movement, pupils, conjunctiva, sclera
Ears	Hearing, external ear, eardrum, discharge
Nose	Patency, mucosa, septum, sinuses
Mouth/Throat	Lips, teeth, gums, tongue, uvula, tonsils
Neck	Lymph nodes, thyroid, carotid arteries

✍️ How to Document HEENT Findings

1. Use Standardized Terminology

Stick to commonly accepted medical terms to ensure clarity and consistency across providers.

Examples:

PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation)
Normocephalic
Midline uvula
Non-tender cervical lymph nodes

2. Be Objective and Specific

Avoid vague language like “looks okay” or “normal.” Instead, describe exactly what you observed.

Good Example:

Eyes: PERRLA, extraocular movements intact, visual acuity 20/20 bilaterally.

Poor Example:

Eyes look fine.

3. Organize by Section

Structure your documentation in the same order as your assessment to help others follow along easily.

📋 Sample HEENT Documentation (Normal Findings)

Here’s an example of how to document a normal HEENT exam in a patient chart or electronic health record (EHR):

HEENT:

Head: Normocephalic, atraumatic, no masses or tenderness noted.

Eyes: PERRLA, visual acuity 20/20 without correction, sclera white, conjunctiva pink, no discharge. Extraocular movements intact.

Ears: External canals clear bilaterally, tympanic membranes pearly gray with visible light reflex, no drainage or erythema.

Nose: Nasal mucosa pink and moist, septum midline, no deviation, turbinates normal size, no nasal discharge.

Mouth/Throat: Lips pink and moist, teeth present in good repair, gums pink and non-bleeding, tongue midline with full mobility, uvula midline, tonsils 1+, no exudate.

Neck: Supple, no lymphadenopathy, thyroid not enlarged, no carotid bruits auscultated.

🚨 Abnormal HEENT Documentation Examples

When documenting abnormal findings, be precise and include relevant details such as location, description, duration, and associated symptoms .

Example 1: Red Eye and Discharge

Eyes: Left eye red with purulent discharge. Visual acuity 20/40 OS, no improvement with pinhole. Conjunctiva injected, cornea clear, pupils reactive but photophobic. Suspected conjunctivitis.

Example 2: Sore Throat and Swollen Tonsils

Mouth/Throat: Tonsils 3+ with white exudate bilaterally. Uvula midline but slightly deviated due to swelling. Patient reports fever and difficulty swallowing for 2 days.

Example 3: Ear Pain and Fluid Behind Eardrum

Ears: Right tympanic membrane bulging and erythematous with decreased light reflex. Mild pain on palpation of tragus. Patient reports decreased hearing and popping sensation.

💡 Tips for Effective HEENT Documentation

✅ Be Consistent

Use the same format every time so your notes are predictable and easy to read.

✅ Use the SOAP Format (if applicable)

If your facility uses SOAP notes , structure your HEENT findings under the Objective section.

Subjective: “I’ve had a sore throat for three days.”
Objective: “Tonsils 2+ with erythema, no exudate.”
Assessment: “Viral pharyngitis”
Plan: “Symptomatic treatment, rest, hydration.”

✅ Know Your Abbreviations

Use only standard abbreviations that are widely recognized in your institution.

✅ Don’t Forget the Patient’s Perspective

Include subjective complaints related to HEENT, such as “blurred vision,” “earache,” or “dry mouth.”

✅ Chart Timely and Legibly

Documentation should happen soon after the assessment while findings are fresh. In paper charts, write legibly; in EHRs, avoid typos.

📌 Quick Reference: Common HEENT Documentation Phrases

Area	Normal Documentation Phrases
Head	Normocephalic, atraumatic, no tenderness
Eyes	PERRLA, visual acuity 20/20, sclera white, conjunctiva pink
Ears	TM pearly gray, canals clear, no discharge
Nose	Septum midline, mucosa pink, no discharge
Mouth	Lips pink/moist, uvula midline, tonsils 1+
Neck	No lymphadenopathy, thyroid non-palpable, no bruits

📝 Final Thoughts

Effective HEENT documentation is more than just checking boxes—it’s a way to communicate your clinical findings accurately and professionally. Whether you’re a student learning to chart or a seasoned nurse refining your skills, taking the time to document clearly will improve patient outcomes and enhance teamwork.

Remember: Good documentation isn’t just about writing down what you see—it’s about telling the patient’s story in a way that supports safe, effective care.

🔍 Want More Clinical Documentation Help?

Check out our other posts:

How to write a SOAP note for nursing students
Head-to-toe assessment documentation guide
Common mistakes to avoid when charting
How to document neurological assessments

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