HA3005 Tina Jones Comprehensive Physical Assessment Instructions

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Overview – HA3005 Tina Jones Comprehensive Physical Assessment Instructions

For this Performance Task Assessment, you will complete a comprehensive physical assessment on a simulated patient in the Shadow Health platform.

Submission Length: Conduct a comprehensive physical assessment using Shadow Health software. As you complete the steps necessary to conduct a comprehensive physical assessment, you will also document your progress in Shadow Health.

Instructions

To complete this Assessment, do the following:

Be sure to adhere to the indicated assignment length.
Review the
Review
Review the
Access the Shadow Health Platform.
Review the instructions that you are given when you log in to Shadow Health.
Review the Assignment Overview for the Physical Assessments in Shadow Health.
Review the Objectives and Instructions for the Physical Assessments in Shadow Health.

Before submitting your Assessment, carefully review the rubric. This is the same rubric the SME will use to evaluate your submission and it provides detailed criteria describing how to achieve or master the Competency. Many students find that understanding the requirements of the Assessment and the rubric criteria help them direct their focus and use their time most productively. HA3005 Tina Jones Comprehensive Physical Assessment Instructions

All submissions must follow the conventions of scholarly writing. Properly formatted APA citations and references must be provided where appropriate. Submissions that do not meet these expectations will be returned without scoring.

This Assessment requires submission of “Lab Passes” and both objective and subjective documentation for each of the body systems. The submission can be completed one of two ways. Please use whichever way is easiest for you to complete.

Option 1: Submit one file
- One file containing your “Lab Pass” and documentation for each of the seven individual physical exams on body systems. Save your file as HA3005_assessment_firstinitial_lastname (for example, HA3005_assessment_J_Smith).
Option 2: Submit separate files
- Submit the “Lab Pass” and documentation for each single system exam. Each file should be saved as HA3005_Name of System_firstinitial_lastname (for example: HA3005_SkinHairNails_J_Smith).

When you are ready to upload your completed Assessment, use the Assessment tab on the top navigation menu.

Important Note: As a student taking this Competency, you agree that you may be required to submit your Assessment for textual similarity review to Turnitin.com for the detection of plagiarism. All submitted Assessment materials will be included as source documents in the Turnitin.com reference database solely for the purpose of detecting plagiarism of such materials. Use of the Turnitin.com service is subject to the Usage Policy posted on the Turnitin.com site.

For this Assessment, you will complete seven (7) individual physical exams on body systems and capture your documentation for each individual physical exam in the Shadow Health platform. The seven individual exams are:

Skin, Hair, and Nails
HEENT
Respiratory (Lungs)
Cardiovascular (Heart)
Abdominal
Musculoskeletal
Neurological

Note: The Shadow Health concept labs for cardiovascular, respiratory, and abdomen are not needed for submission. Only their single-system assessments should be submitted.

You are the nurse providing care for a patient as part of their admission to Shadow General Hospital. After completing your patient interview, you will perform a comprehensive physical assessment on your patient.

In Shadow Health, complete the following:

Perform the seven (7) physical assessments of your patient’s body systems.
Narratively document your engagement with your patient as you perform each of the physical assessments.
Obtain a Lab Pass and a copy of your narrative documentation of each of the physical assessments for submission of this Assessment.

Shadow Health Student Guide – HA3004 & HA3005 (HA3005 Tina Jones Comprehensive Physical Assessment Instructions)

Contents

What is the Shadow Health Digital Clinical Experience™ (DCE)? ………………………………………… – 1 – Technical Requirements ……………………………………………………………………………………………….. – 2 –
Shadow Health Support ………………………………………………………………………………………………… – 2 –

How to Access Shadow Health ………………………………………………………………………………………. – 2 –

Shadow Health Assignments …………………………………………………………………………………………. – 3 –

First Turn-In ………………………………………………………………………………………………………….. – 3 –

Reopening ……………………………………………………………………………………………………………. – 3 – Submitting Shadow Health Assignments……………………………………………………………………. – 4 – Troubleshooting …………………………………………………………………………………………………………… – 5 –
Digital Patient Conversation …………………………………………………………………………………….. – 5 –

Garbled or No Audio ………………………………………………………………………………………………. – 5 –

Slow Loading, Slow Response…………………………………………………………………………………. – 5 –

Overheating ………………………………………………………………………………………………………….. – 5 –

Help Desk Articles………………………………………………………………………………………………………… – 6 –

Legacy Access…………………………………………………………………………………………………………….. – 6 –

What is the Shadow Health Digital Clinical Experience™(DCE )?

Shadow Health provides a clinical simulation designed to improve your assessment skills in a safe learning environment. You will examine digital patients throughout the course that are accessible online 24/7.

Our Digital Clinical Experience is free of many of the constraints and interruptions you face in a hospital or clinical setting. This unique simulation experience allows you to conduct in-depth patient exams and interviews at your own pace. Because the exams are in-depth, these assignments will often take over an hour to complete, so it is important to plan enough time to complete your assignments each week.

You access your Shadow Health assignments through a special single sign-on link in the Tempo Brightspace page for HA3004 and HA3005. This is the only way to correctly access your Shadow Health assignments.

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Shadow Health Student Guide – HA3004 and HA3005

Technical Requirements

• Review requirements: http://link.shadowhealth.com/Minimum-System-Specifications
• Tablets and mobile devices are not currently supported.
• To use Speech-to-Text, you must use Google Chrome as your browser.
• Third-party cookies are required for LTI to work properly:
Allow Third-Party Cookies in Chrome

Shadow Health Support

Contact Shadow Health with any questions or technical issues regarding Shadow Health before contacting your instructor. Support is available http://support.shadowhealth.com

How to Access Shadow Health

1. In Brightspace, navigate to the HA3004 or HA3005 page with the Shadow Health link.

2. Click the link to access your Shadow Health course shell for the current term.
You do not need a course PIN to enroll. If it requests a PIN, log out and try using another browser. That will normally fix the problem.
3. Shadow Health will open within Brightspace and you can complete your assignments there.

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Shadow Health Student Guide – HA3004 and HA3005

Shadow Health Assignments

First Turn-In

This course allows you to make multiple assignment attempts, but it is your first attempt that is accepted as a grade. To properly self-remediate, you should reopen and make corrections to their first attempt only. HA3005 Tina Jones Comprehensive Physical Assessment Instructions

You can reopen it as many times as you like prior to the assignment due date.

Reopening

In this course, you can make corrections on completed assignment attempts by reopening prior to the due date. For details on how to reopen your assignments, consult the Reopening article by our Help Desk.

Only your first attempt will be accepted for a grade, but you can reopen it as many times as you like prior to the assignment due date.

When making corrections to improve your score, do not start a new attempt. Instead, select to Reopen and Resume your first attempt.

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Shadow Health Student Guide – HA3004 and HA3005

Submitting Shadow Health Assignments

Once you have clicked the Submit button in Shadow Health after each assignment, you will need to gather information to submit in HA3004 and HA3005. Keep in mind that all files must be ready to submit at one time in Tempo. Students cannot submit a few files and then go back later to submit the rest of them in Tempo.

For HA3004, this competency focuses on the health history. When submitting, you will need two pieces of information (1) Health History Digital Clinical Experience (DCE) score and (2) documentation of the health history. The DCE score is found in the lab pass section of Shadow Health. It will be saved as a PDF file. To obtain the documentation, go in the Health History in Shadow Health, select the ‘documentation’ tab. Once in the documentation tab, select ‘shift assessment’. There, you will find the health history. Copy this information and then paste it into a Word document.

For HA3005, it is a similar process to HA3004. However, you will have multiple files. For each single system assessment, you will obtain the (1) Digital Clinical Experience (DCE) score and (2) subjective and objective documentation related to that system. The DCE score is found in the lab pass section of Shadow Health. It will be saved as a PDF file. To obtain the documentation, go to the single system assessment in Shadow Health. Select the ‘document’ tab followed by ‘document: nursing notes’. In this section, copy both the subjective and objective data. Then, paste in a Word document.

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Shadow Health Student Guide – AH001

Troubleshooting

Digital Patient Conversation

For issues related to patient conversation, we advise:
1. Revisit the Conversation Concept Lab, if permitted.
2. Review best practices our Tips & Tricks article:
https://link.shadowhealth.com/Tips-and-Tricks
3. Watch our Tips & Tricks video with Nurse Educator, Julie Byrne:
https://link.shadowhealth.com/tipstricksvid HA3005 Tina Jones Comprehensive Physical Assessment Instructions

Garbled or No Audio

This happens when using Microsoft Edge or Safari as your browser. We recommend
Google Chrome or Mozilla Firefox.

Slow Loading, Slow Response

If the DCE is taking a long time to load and/or respond, three of the likeliest causes are:
1. Your computer is not plugged in
Relying only on battery significantly reduces the processing power of your computer.
2. Your browser is out of date or not supported
Shadow Health DCEs are optimized for Google Chrome and Mozilla Firefox. Be sure you have installed the most up-to-date version.
3. Your internet connection is slow
A download speed of at least 3 mbps is required to run Shadow Health. You can test your internet connection at speedtest.net.
4. Your computer does not meet requirements
Check our Tech Specs page to see if your computer meets the system specifications.
If you find your computer does not meet these, contact our Help Desk for advice.

Overheating

If you find your computer is getting very hot, make sure:
1. Remove your laptop’s case or chassis
These do not allow computers to ventilate as they are supposed to.
2. Place your computaer on a solid, flat surface
Placing a laptop on a soft surface inhibits ventilation.

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Shadow Health Student Guide – AH001

Help Desk Articles

Feel free to explore the useful articles from our Help Desk.

Legacy Access

You can access Shadow Health assignments for as long as you have access to your school email. After your course is finished, go to the Password Reset page and enter your school email address. This will give you access for 24 hours and can be repeated as many times as you need.

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Heath Assessment Nursing Documentation

In each of the Shadow Health (SH) exams you will be asked to complete a narrative note as part of the grading criteria. Narrative or progress notes are often a new skill for nurses. This document is provided to assist students in understanding how to write a narrative nursing note. Shadow Health refers to these notes as Shift Assessment or Nursing Progress Note.

Documentation of patient care is essential to quality and safety of care. Much of the clinical documentation is completed electronically using point and click tools to describe the patient condition (Lindo, et al., 2016). Often computer prompts fall short of fully describing the patient condition. Other situations such as lack of technology, electrical outages, system hacking, failure of equipment, and any number of situations which may interfere with normal electronic documentation may require a narrative nurses/progress note. Nurses must be able to clearly communicate patient information with everyone on the health care team to ensure quality and safety of care (Lindo, et al., 2016).

Documentation must be clear, paint a picture of the patient, and provide measurable concise information in a timely manner. The information communicated must be able to be understood by others and provide enough information to understand if a change has occurred in the patient condition and to clearly communicate all treatments, interventions, and therapies received by the patient and/or planned for the patient. Documentation also serves as a legal record of care (Lippincott Williams and Wilkins, 2007).

Documentation begins with subjective data/information. This is information the patient, family member, or caregiver may provide if the patient is unable to communicate which includes such data as the history of present illness (HPI), the past history- medical surgical & social and the review of systems (ROS). Objective data/information includes the physical exam, observations and measurements obtained during the examination of the patient. Objective data also includes vital signs, laboratory and diagnostic results (Jarvis, 2016a).

Data gathering begins with subjective data followed by the objective data and is to progress in a cephalocaudal, meaning head to toe, format. Objective data will also be documented in a cephalocaudal manner and in order of the assessment techniques inspection, palpation, percussion, and auscultation. The assessment technique order is important and only varies for the abdominal assessment and in special circumstances such as patient condition and ability to move or follow direction (Jarvis, 2016a). Note, the Narrative Note, Nurses Note, or Shift Assessment is to contain headings for each body system being assessed. The assessment skill being used is not generally named or used for organizing the note. See the examples below for reference.

Subjective information assists in understanding the patient condition and provides a basis upon which the nurse decides which body systems need to be assessed and which assessments need to be completed. Many of the assessments to be performed in the class are focused or problem based and focus on the assessment of a specific body system. The Comprehensive assessment is a complete health history and physical exam of most all body systems (Jarvis, 2016b).

Once subjective and objective information are obtained and have been thoroughly considered an assessment/nursing diagnosis or medical diagnosis (physicians and advanced practice only) is identified. A plan of care will then be developed based on the nursing diagnoses. In the health assessment competencies, the primary focus is on gathering accurate subjective and objective data (Jarvis, 2016b).

Subjective data should be recorded using the patient’s own words and describing his/her feelings and experiences related to health. When interviewing the patient about a current issue or illness the eight critical characteristics (CCs) need to be included in the documentation (Jarvis, 2016a). The eight CCs would be asked for any positive response during the health history (HH) and review of systems (ROS). Here is a list of the CCs and a few sample questions for a patient with complains of abdominal pain (Jarvis, 2016a). HA3005 Tina Jones Comprehensive Physical Assessment Instructions

Location: “Where does it hurt?” “Please point to the area of pain.”
Character or Quality: “How would you describe the pain?” “Is it sharp pain?” “Dull pain?”
Quantity or Severity: “On a scale of 0-10, 0 being no pain and 10 being the worst pain ever, what is your level of pain?” “How has the pain impacted your daily routine?”
Timing: “When does the pain occur?” “How long does it last?” “Approximately how long after you have eaten does the pain begin?” ”Does the pain radiate?” “If yes, where does it radiate?”
Setting: “What were you doing when the pain began?”
Aggravating or Relieving Factors: “Is the pain worse after eating certain foods?” “What makes the pain better?”
Associated Factors: “Do you have any nausea or vomiting?” “Any diarrhea?” “Any constipation?”
Patient’s Perception: “What do you think the pain means?”

Another way to remember what to ask the patient is to use the mnemonic PQRSTU (Jarvis, 2016a, p. 51).

P: Provocative or Palliative

Q: Quality or Quantity

R: Region or Radiation

S: Severity Scale

T: Timing

U: Understand Patient’s Perception

When documenting the ROS it is necessary to document each condition or item asked about because others will be reading the notes and relying on the information provided. If information is incomplete or inaccurate patient safety and quality of care may be affected. It is unacceptable to document: “No problems”, “WNL”, “Negative”, or “No complaints”. These terms do not describe what was assessed, seen, felt, heard, measured, or smelled (Jarvis, 2016a).

ROS (Subjective) Documentation Example:

Review the following ROS areas and the associated documentation and note the quality of the information provided for each system.

Skin: Denies any history or issues with eczema, psoriasis, hives, changes in color of skin, changes in moles size or shape, or color, dry skin, open areas/wounds, or excessive moisture. States does have a red rash on her left wrist, the rash began about a week ago, itches most of the time, some moisture from the rash, denies pain at the site, has tried some Benadryl with some relief, thinks it gets worse after she wears a particular bracelet and thinks it may be related.

Hair: States feels like her hair is, “lacking” explains she thinks it falls out a lot. Denies change in color or texture. Denies change in shape, color, or brittleness of nails and adds she has never been able to grow long nails as they seem to be soft and bend.

Head: No problems with head or headaches.

Eyes: No problems, says they are normal.

(Jarvis, 2016c)

Skin and hair are documented correctly, they both provide specific information of the conditions asked and the patient responses. Skin also includes the eight CCs of the patient issue related to a rash on her left wrist. Head and eyes subjective documentation does not contain enough information. Another nurse reading this documentation would not know if the patient had been asked about most possible issues related to the head or eyes. Therefore, an incomplete picture of the patient would be obtained. This may lead to rework or incorrect care plan and interventions (Jarvis, 2016c).

Assessment (Objective) Documentation Example:

Skin: Uniform in color, tan, warm, dry, intact. Turgor good, skin returns immediately when released. Scattered flat small macules on face around nose. On back of left shoulder 4mm, symmetrical, smooth borders, dark brown, evenly colored, slightly raised nevus, without tenderness or discharge. Well healed pale scar 3 cm right forearm. Left wrist approximately 1 cm area around the circumference of the wrist pruritic papules and vesicles with an erythematous base. Silver colored striae around lower outer quadrants of abdomen and hips.

Nails: normal shape and contour, soft, capillary refill good.

Hair: Brown

Eyes: Eye color brown. brows, lids, and lashes symmetric, right brow ridge piercing with intact silver hoop, no redness, tenderness, or discharge; lacrimal ducts pink and open without discharge. Conjunctiva clear, sclera white, moist, and clear, no lesions or redness, no ptosis, lid lag, discharge or crusting. Snellen vision assessment 20/20 in each eye with corrective lenses. EOMs intact, no nystagmus, PERRLA

(Jarvis, 2016c)

Skin is documented very complete and concise a picture of the patient is evolving and measurable assessment data is provided. Complete description of the rash on the left wrist provides a measurable concise picture. A mole was noted and documentation included the ABCDE of the mole. It is important to describe both normal and abnormal findings in a measurable manner. The text offers examples of how to provide measurable information for many assessment findings such as tonsils, pulses, reflexes, and strength (Jarvis, 2016c).

The documentation for nails is less measurable. How is one to know what “normal shape and contour is for this patient? The nails are not described. The shape, contour, profile, consistency, color and capillary refill should be documented. Capillary refill is noted but not measurable. What is considered “good”. A patient with chronic COPD “good” capillary refill may be greater than 4 seconds and someone without a respiratory “good” may be less than 3 seconds. Terms such as “good”, “fair”, etc. are not measurable and are rarely used in assessment.

The assessment information related to hair only provides the color, no information about texture, distribution, thickness, etc. are provided. These are all important to note.

The documentation for the eyes is very thorough and concise. Measurable terms are used and a description of the patient’s eyes is provided. HA3005 Tina Jones Comprehensive Physical Assessment Instructions

Some of the Shadow Health (SH) exams focus on one body system such as Cardiac. In this situation focus on pertinent questions related to the ROS and physical assessment for cardiac and any associated body systems. In the case of cardiac, peripheral vascular and respiratory would be additional systems to assess.

When completing the assessments in SH use the text as a guide. Open to the appropriate chapter and follow along to ensure all aspects of the assessment are covered for both subjective and objective assessment areas. Document carefully for each assessment area keeping in mind the differences between subjective and objective information and ensuring measurable concise information is recorded.

Subjective and objective information is separated and each body system is used as a heading for easier retrieval of information. When information is disorganized it is difficult to know which is the information provided by the patient and which is the objective clinical assessment data. In an emergency retrieval of information must be done quickly. Well organized and written notes allow for timely retrieval (Lindo et al., 2016).

References

Jarvis, C. (2016a). Physical examination and health assessment (7th ed.). The complete health history (pp. 49-66). St. Louis, MS: Elsevier.

Jarvis, C. (2016b). Physical examination and health assessment (7th ed.). Evidence-based assessment (pp. 1-9). St. Louis, MS: Elsevier.

Jarvis, C. (2016c). Physical examination and health assessment (7th ed.). The complete health assessment: Adult (pp. 775-788). St. Louis, MS: Elsevier.

Lindo, J., Stennett, R., Stephenson-Wilson, K., Barrett, K.A., Bunnaman, D., Anderson-Johnson, P., Waugh-Brown, V., and Wint, Y. (2016). An audit of nursing documentation at three public hospitals in Jamaica. Journal of Nursing Scholarship, 48(5), 508-516.

Lippincott Williams & Wilkins (2007). Charting: An incredibly easy pocket guide. Ambler, PA: Author.

Health Assessment Outline

Health History

Chief Complaint

This should be a few of the patient’s own words indicating why they have come for care.

History of Present Illness

This is the PQRST or OLD CART of why the patient is here. Detail is important.

Pain Assessment

Document all the information about the patient’s pain. Part of this may be contained in the PQRST or OLD CART information.

Allergies

List all allergens and the reaction.

Immunizations

List all immunizations.

Medications

List all current home medications, dosage, frequency, and route including over the counter and PRN medications.

Medical History

Provide a brief overview of medical history including age of onset of conditions, treatments, and results, last eye, dental, GYN, checkups.

Surgical History

List all previous surgeries

Previous Hospitalizations

Document all hospitalizations including the reason

Gynecological History

Document all GYN history including menses history, sexual history, pregnancy etc. Provide detailed information.

Family History

Include all family members for three generations, illnesses, age, cause of death if applicable in an organized manner. Make sure to correctly identify maternal and paternal relatives.

Social History

Include living situation, education, job, activities, support systems, financial situation, tobacco use, alcohol and recreational drug use, and relationships.

Review of Systems

Document subjective data about past and present health. Each body system needs to be listed and each condition asked about for the related body system needs to be documented. If a positive, other than the Chief Complaint, is noted the PQRST/OLD CART of the issue is to be documented.

Hair, Skin, and Nails (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

- Subjective
  - Include the PQRST of any positive answer.
  - Past history of skin disease
  - Injury
  - Change in pigmentation
  - Change in moles
  - Excessive dryness
  - Pruritus
  - Excessive bruising
  - Rashes or lesions
  - Hair loss or growth
  - Change in nails
  - Foot wound
- Objective
  - General Survey
  - General pigmentation
  - Moisture
  - Texture
  - Thickness
  - Edema
  - Mobility and Turgor
  - Lesions
  - Foot Wound
  - Moles (ABCDE)
  - Hair
  - Nails

HEENT (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.) HA3005 Tina Jones Comprehensive Physical Assessment Instructions

Subjective

- Head
  - Headache
  - Head Injury
  - Dizziness
  - Neck pain
  - Lumps or swelling
  - History of head or neck surgery
- Eyes
  - Vision difficulty
  - Pain
  - Diplopia or strabismus
  - Redness/Swelling
  - Discharge/Watering
  - Use of glasses or contacts
- Ears
  - Earache
  - Infections
  - Discharge
  - Hearing loss
  - Environmental noise
  - Tinnitus
  - Vertigo
- Nose
  - Discharge
  - Colds
  - Sinus issues/pain
  - Trauma
  - Epistaxis
  - Allergies
  - Altered smell
- Mouth/Throat
  - Sores or lesions
  - Sore throat
  - Bleeding gums
  - Tooth pain
  - Hoarseness
  - Dysphagia
  - Altered taste
  - Tobacco and alcohol use
Objective
- General Survey
- Head
  - Size and shape
  - Hair
  - Scalp
  - Facial structures
  - Neck
  - Lymph
- Eyes
  - Visual acuity
  - General ocular structures
  - Diagnostic positions/EOMs
  - Pupillary response
- Ears
  - Size, shape
  - External structures
  - Ear canal
  - Tympanic membranes
  - Whispered test
- Nose
  - External structures of nose
  - Patency of nares
  - Sinuses
- Mouth and Throat

Teeth
Gums
Tongue
Buccal mucosa
Palate
Throat
Tonsils

Respiratory (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

Subjective
Cough
SOB
Chest Pain
Respiratory Infections
Smoking
Environmental Exposure

Objective

General Survey
HEENT-Brief
Cardiac-Brief
Chest Symmetry
Fremitus
Percussion
Diaphragmatic Excursion
Breath Sounds

Cardiovascular (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

Subjective

Chest pain
Dyspnea
Orthopnea
Cough
Fatigue
Cyanosis or Pallor
N/V
Edema
Nocturia
Cardiac History
Leg Pain/Cramps
Skin Changes
Surgical history

Objective

General Survey
Carotid
JVD
Precordium
Apical Impulse
Auscultation/Heart Sounds
pulses upper and lower and grade of pulses
Edema

Abdominal (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

Subjective

- - Appetite
  - Dysphasia
  - Abdominal Pain
  - Nausea/Vomiting
  - Bowel habits
  - Change in bowel habits
  - Dark or blood in stool
  - Abdominal History
Objective
- - General Survey
  - Abdominal Contour
  - Symmetry
  - Skin
  - Pulsations
  - Hair Distribution
  - Bowel Sounds
  - Vascular Sounds
  - Percussion
  - CVA Tenderness
  - Light and Deep Palpation
  - Liver
  - Spleen

Musculoskeletal (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

Subjective
Joints
Pain
Stiffness
Swelling, Heat, Redness
Limitation of Movement
Muscles
Pain (cramps)
Weakness
Bones
Muscle Pain
Deformity
Trauma (fractures, sprains, dislocations)
Functional Assessment (ADLs) Brief statement
Objective
General Survey
Joints (size, contour)
ROM (List each joint tested. Do not need to include degrees. State if full or limited. If limited, explain the limitation.)
Crepitus
Strength of major joints/muscle groups and the grade
Spine ROM and strength
Foot wound

Neurological Exam (See the text for specifics for each area. The minimum narrative documentation should include the following as well as the PQRST of the issues identified.)

Subjective

- - Headache
  - Head injury
  - Dizziness/vertigo
  - Seizures
  - Tremors
  - Weakness
  - Incoordination
  - Numbness or tingling
  - Difficulty swallowing
  - Difficulty speaking

Objective

- - General Survey
  - Basic Memory
  - Basic summary statement of cranial nerve function (symmetry of face, pupillary reaction, speech and phonation)
  - Rapid alternating movements
  - Stereognosis
  - Graphesthesia
  - Sensation to all extremities
  - DTRs (Name and grade each tested)
  - Proprioception
  - Romberg

Comprehensive Exam (It has been some time since you have seen Tina and all questions and information must be covered and documented as if this were the first meeting.)

Vitals

Document the patient’s vital signs

Health History

Identifying Data and Reliability

Basic identifying data and if the patient is a reliable source for information.

General Survey

Brief statement of overall appearance, dress, attitude, is the patient in distress, smiling, crying, well groomed, etc.

Reason for Visit

Why is Ms. Jones here today? In her words.

History of Present Illness

Brief statement of why she is here and any related factors.

Medications

List all current home medications, dosage, frequency, and route including over the counter and PRN medications.

Allergies

List all allergens and the reaction when exposed.

Medical History

Provide a brief overview of medical history including age of onset of conditions, treatments, and results.

Health Maintenance

Include activities the patient does to maintain health. Immunizations, seat belt use, regular check-ups, last eye exam, dental exam, fire alarms in the home, exercise, diet, etc. HA3005 Tina Jones Comprehensive Physical Assessment Instructions

Family History

Include all family members for three generations, illnesses, age, cause of death if applicable in an organized manner. Make sure to correctly identify maternal and paternal relatives.

Social History

Include living situation, education, job, activities, support systems, financial situation, tobacco use, alcohol and recreational drug use, and relationships.

Mental Health History

Any stress, anxiety, depression, etc. A brief statement.

Review of Systems-General

Provide a general statement of overall health. Each body system will be reviewed in the next section.

HEENT

Subjective

Document the basic subjective data from the HEENT exam completed earlier. List the conditions asked about and if the patient denies having. If there is an issue document the PQRST of the issue.

Objective