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  • Area Assessed Methods Findings Interpretation

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    Timmy Caras
    15 views2 pages
    This document contains a template for documenting a physical assessment of a patient. It includes sections to record vital signs, general appearance, mood, and behavior. It then lists 13 body areas that can be assessed including skin, hair, nails, eyes, ears, nose, mouth, neck, chest, abdomen, and extremities. For each area there are columns to document the assessment method, findings, interpretation. The overall document provides a structured format to record a comprehensive physical exam.

    Original Description:

    health assessment

    Original Title

    HA

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    This document contains a template for documenting a physical assessment of a patient. It includes sections to record vital signs, general appearance, mood, and behavior. It then lists 13 body areas that can be assessed including skin, hair, nails, eyes, ears, nose, mouth, neck, chest, abdomen, and extremities. For each area there are columns to document the assessment method, findings, interpretation. The overall document provides a structured format to record a comprehensive physical exam.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    15 views2 pages

    Area Assessed Methods Findings Interpretation

    Uploaded by

    Timmy Caras
    This document contains a template for documenting a physical assessment of a patient. It includes sections to record vital signs, general appearance, mood, and behavior. It then lists 13 body areas that can be assessed including skin, hair, nails, eyes, ears, nose, mouth, neck, chest, abdomen, and extremities. For each area there are columns to document the assessment method, findings, interpretation. The overall document provides a structured format to record a comprehensive physical exam.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    Date:

    Time:
    Vital Signs:
    Temp:
    CR:
    RR:
    BP:

    General Appearance


    Mood


    Behavior


    AREA ASSESSED METHODS FINDINGS INTERPRETATION
    1. SKIN
    COLOR

    INSPECTION
    TEXTURE

    INSPECTION
    TEMPERATURE

    PALPATION
    MOISTURE

    PALPATION
    TURGOR

    PALPATION
    2. HAIR
    DISTRIBUTION

    INSPECTION
    TEXTURE

    INSPECTION
    COLOR

    INSPECTION
    3. NAILS
    COLOR OF NAIL
    BED

    INSPECTION
    CAPILLARY
    REFILL TIME

    PALPATION
    SHAPE

    PALPATION
    4. EYES/EYEBROW
    SHAPE

    INSPECTION
    SYMMETRY

    INSPECTION
    MOVEMENT

    INSPECTION
    ABILITY TO BLINK

    INSPECTION
    5. CONJUCTIVA
    COLOR INSPECTION

    PUPIL

    INSPECTION
    6. EXTERNAL AUDITORY CANAL
    HEARING

    INSPECTION
    7. NOSE
    SYMMETRY

    INSPECTION
    COLOR

    INSPECTION
    8. LIPS AND MOUTH
    SYMMETRY

    INSPECTION
    COLOR

    INSPECTION
    MOISTURE

    INSPECTION
    9. NECK
    APPEARANCE

    INSPECTION
    10. THORAX
    GENERAL

    INSPECTION
    CHEST CONTOUR

    INSPECTION
    CHEST WALL

    INSPECTION
    BREATHING
    PATTTERN
    INSPECTION
    TENDERNESS

    PALPATION
    BREATH SOUNDS

    AUSCULTATION
    11. ABDOMEN
    GENERAL
    CONTOUR
    INSPECTION
    12. UPPER EXTREMITIES
    SYMMETRY

    INSPECTION
    ROM

    INSPECTION
    13. LOWER EXTREMITIES
    SIZE

    INSPECTION
    SYMMETRY

    INSPECTION
    ROM

    INSPECTION

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