Ooo, ouch. Rookies close your eyes and hum.
You thought right. I'm not talking about letters I'm talking about real life. If we were held to all the applicable official letters and standards we would see one pt a day.
It comes in three stages. The first stage is when you are not a "known quantity" you have to report everything about the pt to prove you aren't totally fixated on one complaint or just missing important stuff. If you are seeing the pt the fourth time for a plantar wart you had better record their lung sounds despite absence of other indicators or complaints.
Second phase is that your charting indicates that you did appropriate exam by listing every finding appropriate to the reason you are seeing the pt, or any incidental findings or c/o which arise. If I'm seeing Bonzo the fourth time for warts and he has a cough, I listen in and if it's important I go there. If not, the next person reading my chart doesn't want to hear about my ruling something out in 99% of instances, they want to hear about this plantar wart I'm treating. Well, maybe they don't want to, but tough.
Third stage is as a "reasonable" experienced practitioner within the community standard (not necessarily the microtome-like standard some beancounters espouse), if it can be reasonably surmised that I know what I'm doing when I chart WNL, then it can be reasonably expected to be that. If your organization expects second stage to be their level, that's great, and very appropriate for ICU etc pt care, but I'm betting a Twinkie I could go into any pt chart and find MD's and others charting WNL, unremarkable, etc. Most just don't mention it at all, avoiding the red flag nitpickers go for.
The basis for all this is you know what you are doing and doing it right. My docs would skin me alive if I wasted their and my time by doing rookie-level documentation, and the last supervisor who tried that on me and the experienced nurses was let go.