PHYSICAL ASSESSMENT DOCUMENTATION GUIDE
Student____________________________ Date ________________
Client/Patient ___________________________Age ________Sex__________
General State of Health
Subjective Data: (Obtain all info under “General State of Health” from Review of Systems page 5 of Jarvis)
Objective Data:
Appearance
Posture
Overall hygiene and grooming
Any apparent signs of distress
Dress
Behavior
Level of consciousness
Mood and affect/ Facial expressions (appropriate for situation) Cognition
Orientation (person, place, time, and purpose-X4)
Speech (clear, garbled, slurred, incomprehensible)
Responsiveness (follows directions and responds appropriately)
Documentations: (Include both Subjective and Objective Data in Narrative Form)
PHYSICAL ASSESSMENT DOCUMENTATION GUIDE
Student____________________________ Date ________________
Client/Patient ___________________________Age ________Sex__________
Assessment of the Skin, Hair, and Nails
Subjective Data: (Obtain all info under “Skin”, “Hair”, & “Nails” from Review of Systems page 5 Jarvis)
Objective Data:
Inspection and palpation of the skin
Color(pink, cyanotic, jaundiced, erythematous),
Pigmentation (even, hyper/hypopigmentation)
Lesions (Describe 3)
Description – size & color
Structure - type of lesion (macule, papule, nodule etc.)
Anatomical Distribution
Hydration – skin turgor (immediate recoil, tenting)
Temperature & Moisture
Inspection and palpation of the hair
Color & condition
Quantity, distribution, & texture
Inspection and palpation of the fingernails
Color of nail bed
Firmness, texture, ridging, irregularities
Clubbing:
Palpate for firm nail matrix
Estimate nail angle
Documentation: (Include both Subjective and Objective Data in Narrative
Form)
PHYSICAL ASSESSMENT DOCUMENTATION GUIDE
Student____________________________ Date ________________
Client/Patient ___________________________Age ________Sex__________
Assessment of the Head and Neck
Subjective Data: (Obtain all info under “Head, Eyes, Ears, Nose, Mouth and Neck” from Review of Systems page 5-6 Jarvis)
Objective Data:
Inspection and palpation of the head and face
Skull for symmetry & tenderness
Face (includes eyes, ears, nose, mouth, and neck)
Symmetry
Discoloration
Lesions
Drainage
Distention
Oral mucous membranes –color, hydration, lesions
Documentation: (Include both Subjective and Objective Data in Narrative Form)
PHYSICAL ASSESSMENT DOCUMENTATION GUIDE
Student____________________________ Date ________________
Client/Patient ___________________________Age ________Sex__________
Assessment of the Chest and Lungs
Subjective Data: (Obtain all info under Respiratory from Review of Systems in Jarvis page 6)
Objective Data
Inspect chest wall
Color, Configuration (symmetry) and Lesions
Movement
Respiratory rate, depth, and effort
Auscultate systematically for quality of lung sounds
Assessment of lung sounds and location
(Clear, diminished, absent)
Identify adventitious sounds if present:
Wheezes (sibilant or sonorous rhonchi)
Crackles (fine or course)
Documentation: (Include both Subjective and Objective Data in Narrative Form)
PHYSICAL ASSESSMENT DOCUMENTATION GUIDE
Student____________________________ Date ________________
Client/Patient ___________________________Age ________Sex__________
Assessment of the Heart and Peripheral Vascular System
Subjective Data: (Obtain all info under Cardiovascular, Peripheral Vascular
from Review of Systems page 6 Jarvis)
Objective Data
HEART
Inspection
Pulsations, lifts, heaves
JVD with chest at 35-45 degree angle
Auscultation
Rhythm assessment of S1 and S2 (Regular/Irregular)
Assess all auscultatory sites: APETM
Count Apical Heart Rate
PERIPHERAL VASCULAR SYSTEM
Palpation of Peripheral Pulses
Radial
Femoral
Posterior Tibial
Dorsalis Pedis
Skin color – extremities (upper and lower)
Capillary refill after blanching (secs)
Fingers/toes
Presence of Edema- depress for 5 seconds (grade if pitting)
Documentation: (Include both Subjective and Objective Data in Narrative
Form)
PHYSICAL ASSESSMENT DOCUMENTATION GUIDE
Student____________________________ Date ________________
Client/Patient ___________________________Age ________Sex__________
Assessment of the Abdomen
Subjective Data: (Obtain all info under Gastronintestinal, Genitourinary
from Review of Systems page 6-7 Jarvis)
Objective Data
Inspection
Contour
Lesions
Scars
Distention
Pulsations
Hernia (while patient lifts head)
Auscultation (all quadrants)
Bowel sounds
Palpation
Light palpation
Tension of abdominal wall (soft, firm, hard)
Tenderness
Masses
Deep palpation
Tenderness
Masses
Enlarged organs
Percussion
CVA tenderness
Documentation: (Include both Subjective and Objective Data in Narrative
Form)
PHYSICAL ASSESSMENT DOCUMENTATION GUIDE
Student____________________________ Date ________________
Client/Patient ___________________________Age ________Sex__________
Assessment of the Musculoskeletal System
Subjective Data: (Obtain info from Review of Systems under Musculoskeletal in Jarvis)
Objective Data
Muscle strength
Check each muscle group against resistance
Compare right with left:
Upper extremities
Triceps
Biceps
Adduction arms
Abduction arms
Wrists – flexion, extension
Lower extremities
Quadriceps
Hamstrings
Abduction knees
Adduction knees
Plantar flexion feet
Dorsiflexion feet
Documentation: (Include both Subjective and Objective Data in Narrative
Form)
PHYSICAL ASSESSMENT DOCUMENTATION GUIDE
Student____________________________ Date ________________
Client/Patient ___________________________Age ________Sex__________
Neurological Assessment
Subjective Data: (Obtain info from Review of Systems under Neurological in Jarvis)
Objective Data
Mental Status Examination
Appearance (posture, body movement, dress appropriate
for setting, grooming/hygiene)
Behavior (level of consciousness, facial expression,
mood and affect)
Cognition (orientation x4, responsiveness, speech) Thought Processes (thought content for consistency and logic, perceptions
consistency with reality, any suicidal thought)
Pupillary Reaction
(equality, size, shape, reaction to direct and consensual light)
Sensory system
Spinothalamic tract
Light touch
Pain and temperature (only if negative result to light touch)
Posterior column tract
Vibration
Kinesthesia (position sense)
Stereognosis
Graphesthesia
Two-point discrimination
Motor function
Hand grips
Foot pushes
Deep tendon reflexes (Grade)
Biceps C5-C6
Triceps C7-C8
Brachioradialis C5-C6
Quadriceps L2-L4
Achilles L5-S1
Cerebellar Functions
Balance
Gait
Gross motor coordination – heel to toe walking
Romberg
Rapid Alternating Movements (RAM)
Documentation: (Include both Subjective and Objective Data in Narrative
Form)
PHYSICAL ASSESSMENT PRACTICUM
Student____________________________ Date ________________
**Starred ** items are critical elements and must be passed by the student.
Technique Organization Clear Description
(5) (5) Instructions(2) Accurate (4) General Survey:
Appearance (posture, grooming, hygiene,
apparent signs of distress, dress)
Behavior (attitude, mood and affect, facial expressions)
Cognition (mental status, speech, level of orientation)
Skin
Color (pink, cyanotic, jaundice, dusky, pale)
Hydration – skin turgor
Temp. and Moisture (warm/cool, dry/clammy)
Lesions (describes morphology, size, color, pattern of
Arrangement, and distribution)
Head and Neck
Inspection of skull, face (eyes, ears, nose, mouth, , and neck)
Include oral mucous membranes (moist/dry)
Assess for drainage, lesions, distention, discoloration, and symmetry Lungs
Performs inspection before auscultation
Assess respiratory effort and rate
Assess for symmetry of chest wall movement
(chest expansion symmetrical)
Auscultate for breath sounds (anterior or posterior chest)
in a systematic order
Heart
Identify auscultatory sites: nd Aortic – 2 right ICS ndPulmonic – 2 left ICS thTricuspic – Left 5 ICS sternal border or midsternal line th Mitral – left 5 ICS midclavicular line
**Auscultate S1 and S2 - assess rhythm (S1 S2 Reg./irreg.)
assess for extra heart sounds & murmurs thIdentify PMI (left 5 ICS midclavicular line)
Count Apical heart rate (BPM)