Remember if you cannot feel something then it is “nonpalpable,” if you can’t hear something just state they were not heard such as no bowel sounds heard (unless you listened for the full five minutes which we wouldn’t want to do for our purposes – then you could document absent bowel sounds). Be descriptive if necessary but at the same time be brief.
Title:
Documentation of the complete head to toe physical assessment.
Purpose of Assignment:
To demonstrate the ability to document the findings of an objective head to toe assessment and identify abnormal findings.
Course Competency:
Demonstrate physical examination skills of the skin, hair, nails, and musculoskeletal system.
Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.
Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics.
Apply assessment techniques for the neurological and respiratory systems.
Select appropriate physical examination skills for the cardiovascular and peripheral vascular systems.
Instructions:
Content:
- Objective findings including short descriptive paragraph of findings for each section.
- Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Format:
- Standard American English (correct grammar, punctuation, etc.)
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