How to Document a Normal Capillary Refill Exam
Document a normal capillary refill exam as "Capillary refill <2 seconds" or simply "Normal capillary refill" in the extremities section of your physical examination, as this indicates adequate tissue perfusion according to standardized clinical definitions. 1
Standardized Documentation Format
The 2017 AHA/ACC clinical data standards provide the official framework for documenting capillary refill findings 1:
- Normal finding: Document as "Normal" when the nail bed returns to pink color in <2 seconds after pressure is removed 1
- Location: Perform the test on nail beds as the standard site 1
- Context: Include this finding within the "Examination of the Extremities" section of your physical exam 1
Specific Documentation Language
Use this standardized terminology in your medical record 1:
- Preferred documentation: "Capillary refill: Normal" or "CRT <2 seconds"
- Alternative acceptable format: "Capillary refill time normal bilaterally"
- Avoid vague terms: Do not use subjective descriptors like "brisk" or "adequate" without specifying the time threshold 1
Age-Specific Considerations for Normal Values
While the <2 second threshold is the standard clinical definition, be aware of physiologic variations 1:
- Children and adults (<65 years): Normal is <2-3 seconds 1
- Elderly patients (≥65 years): Normal can be up to <4.5 seconds due to age-related vascular changes 2
- Newborns: Mean CRT is approximately 4.2 seconds in hands and 4.6 seconds in feet, with wide normal variation 3
Important caveat: Despite these physiologic variations, clinical guidelines uniformly recommend using the <2 second threshold for documentation purposes in adults and children to maintain standardization 1. The elderly threshold of 4.5 seconds should be noted separately if relevant to clinical context 2.
Complete Documentation Example
When documenting the extremities examination, include capillary refill alongside other perfusion indicators 1:
"Extremities: Warm and dry. No cyanosis, clubbing, or edema. Capillary refill <2 seconds bilaterally. Peripheral pulses 2+ and symmetric."
This format follows the standardized lexicon recommended by the AHA/ACC for ambulatory electronic health records 1.
Clinical Context Integration
Document capillary refill as part of the broader perfusion assessment 1:
- Associated normal findings to document together: warm extremities, absence of skin mottling, well-palpable peripheral pulses, normal mental status 1
- In pediatric patients: Specifically note capillary refill <2 seconds as a therapeutic endpoint when assessing for adequate resuscitation 1
- In shock evaluation: Normal capillary refill helps exclude cold shock but does not exclude warm shock with peripheral vasodilation 1
Common Documentation Pitfalls to Avoid
Do not document 1:
- Subjective terms without time specification ("good refill," "brisk")
- Failure to specify bilateral assessment
- Omitting capillary refill from the extremities exam entirely
- Using non-standardized abbreviations without defining them first
Critical note: While capillary refill is temperature-dependent and can be affected by ambient conditions 2, these factors are typically not documented unless clinically relevant (e.g., hypothermic patient, cold environment) 1.