MODIFIED SKILL REVIEW FORM: FOCUSED ADULT PHYSICAL ASSESSMENT ORGAN OR

SYSTEM: MOUTH AND THROAT

Instruction: mark each item by encircling the number corresponding to the student’s performance.

Scoring and Description:

5 (100%) : complete and accurate testing or procedure; correct use of instrument(s)/ equipment, correct/ accurate
statement of findings or complete testing or procedure; correct/ accurate statement of findings.
4 (90%) : complete testing or procedure; correct use of instrument(s)/ equipment; with minimal errors in testing and
statement of findings or complete testing; with minimal errors in testing and statement of findings.
3(80%) : incomplete testing or procedure, with minor steps in testing omitted or absent; minor error/s in use of
instrument(s) / equipment; minor errors in statement of findings noted or incomplete testing or procedure,
with minor steps in testing omitted or absent; minor errors in statement of findings noted.
2 (70%) : incomplete and inaccurate testing or procedure4, with major errors or critical steps in testing omitted or
absent; incorrect use of instrument(s)/ equipment; major errors and incomplete statement of findings of
findings or incomplete and inaccurate testing or procedure, with major errors or critical steps in testing
omitted or absent; major errors and incomplete statement of findings.
1 (60%) : Failure to perform test or procedure; no statement of findings provided.

ASSESSMENT 5 4 3 2 1
(100%) (90%) (80%) (70%) (60%)
1. Washed hands. 5 4 3 2 1
2. Identified client and established rapport 5 4 3 2 1
3. Provided privacy and explained procedure 5 4 3 2 1
4. Prepared assemble required equipment on 5 4 3 2 1
instruments
5. Positioned client appropriately 5 4 3 2 1
Inspected for the following:
6. Lips for color, symmetry, consistency, contour, 5 4 3 2 1
lesions
7. Mucosa and gums for color, integrity, adherence, 5 4 3 2 1
lesions
8. Salivary glands (check box) Wharton’s and 5 4 3 2 1
stensen’s duct
9. Teeth for number, condition (oral hygiene), dental 5 4 3 2 1
works
10. Tongue for color, moisture, size, texture, coating, 5 4 3 2 1
vessels
11. Labial ang lingual frenulums 5 4 3 2 1
12. Hard (anterior) and soft ( posterior) palates for color 5 4 3 2 1
and integrity
13. Breath and breath sounds 5 4 3 2 1
14. Uvula and tonsils ( color, continuity, integrity, 5 4 3 2 1
lesions, inflammation, size)
15. Posterior pharyngeal wall (pharynx) 5 4 3 2 1
Palpated for the following:
16. Lips and gums 5 4 3 2 1
17. Salivary glands 5 4 3 2 1
18. Tongue 5 4 3 2 1
19. Hard ( anterior) and soft (posterior) palates 5 4 3 2 1
CN Testing
20. V ( ability to chew [ masticate] ) 5 4 3 2 1
21. VII and XII (Facial and Glossopharyngeal- taste) 5 4 3 2 1
22. IX and X ( Glossopharyngeal and Vagus – (check) 5 4 3 2 1
speech, swallow, and gag reflex)
23. XII ( hypoglossal- tongue strenght) 5 4 3 2 1
24. Provided client after care as appropriate 5 4 3 2 1
25. Washed hands 5 4 3 2 1
26. Document findings 5 4 3 2 1
TOTAL

Comments:_______________________________________________________________________________
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Signature of clinical instructor:_______________________ Student’s Signature:_______________

Date:_________________________ Date: ___________________________