How to Answer Documentation Assignment Physcial Questions (Complete Guide)

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Documentation Assignment PHYSCIAL EXAMINATION Document Assignment: Physical Examination Download Document Assignment: Physical Examination Students will have the opportunity to practice on a peer and/or standardized patient during the second simulation day. You are expected to complete a head-to-toe assessment on a classmate during this practice session. Students may utilize the form/rubric below during practice to obtain objective data. This information will be the basis for your physical examination documentation assignment within the course. Helpful hints: During your practice session with your peer, write your findings down. These may be normal and/or abnormal findings. You will need to describe what normal and abnormal mean. For example, instead of documenting “the skin assessment is normal”, you can use descriptors such as “skin is warm, soft, uniform, and appropriate for ethnicity. No evidence of ecchymosis, or lesions.” This allows the grader to understand the things you are assessing. The use of normal will result in point deductions. Do not document things you did not assess! Rubric So what am looking for is a sample documentation of a Physical Head to Toe Exam on a Healthy adult who came in for a wellness check. Documentation Assignment: Physical Exam Criteria Ratings Pts Dermatology Skin Assessment: Nail Assessment: Inspects the skin (hands & arms, legs & feet) Assesses skin temperature, tissue integrity and turgor (sternum) Inspects and palpates the fingernails 4 pts Head Hair condition: Scalp condition: Inspects hair and scalp Palpates hair and scalp 4 pts Face Facial Features: Temporomandibular Joint: Assessment of CN V: Assessment of CN VII: Inspects facial features for symmetry 1 Palpates the temporomandibular joint as the client opens and closes the mouth Palpates temporalis and masseter muscles while clenching the teeth (Cranial nerve V)* Assesses light touch across face (Cranial nerve V) * Asks client to smile, frown, puff out cheeks, raise and lower eyebrows (Cranial nerve VII) 8 pts Eyes Vision: External: Internal: PERRLA (Pupils Equal, Reactive to Light, Accommodation): tests visual acuity (Cranial nerve II)* 2 Inspects external eye structures (lids, lashes, brows) 2 Inspects internal eye structures (conjunctivae, sclerae) 1 Checks pupillary reaction to light (direct and consensual) and accommodation (Cranial nerve III, IV, VI)* 8 pts Ears External: Hearing (whisper test):Inspects auricles 1 Palpates auricles 1 Tests hearing acuity (whispered test) (Cranial nerve VIII)* 4 pts Nose: External: Internal: Patency: Assessment of CN I:Inspects & palpates external nose Inspects internal nose, checks for patency 1 Tests ability to smell (Cranial nerve I) 4 pts Mouth: Teeth: Gingival & Buccal Mucosa: Assessment of CN IX/X: Assessment of CN XII: Tonsils: Inspects lips, teeth and gingival, buccal mucosa 1 Inspects protruded tongue in midline (Cranial nerve XII)* 2 Assess the pharynx (Mobility of uvula as the person phonates “ah”) (Cranial nerve IX, X)* 2 Assess tonsils 5 pts Neck: Teeth: Gingival & Buccal Mucosa: Assessment of CN IX/X: Assessment of CN XII: Tonsils: Inspects structures of the neck (trachea, symmetry) 1 Palpates carotid arteries 1 Tests strength of trapezius (Cranial nerve XI) 6 pts Lymphnodes: Names and Assessment: Occipital 0.5 Posterior auricular 0.5 Pre-auricular 0.5 Submandibular 0.5 Submental 0.5 Superficial cervical 3 pts Range of Motion: Neck: Shoulders: Elbows: Ankles: Spine: Neck: Flexion, hyperextension, lateral bending & lateral rotation (sternocleidomastoid: verbalize Cranial nerve XI)* 3 Shoulders: Forward flexion, hyperextension, internal rotation, abduction, adduction, external rotation 3 Elbows: Flexion, extension, pronation, supination 2 Ankles: Plantar flexion, dorsiflexion, eversion, inversion 2 Spine: Flexion, hyperextension, lateral bending, rotation 10 pts Upper Extremities: Radial Pulses: Capillary Refill: Palpates radial pulses 1 Assesses capillary refill (fingers) 2 pts Thorax: Appearance: Palpation Findings: Auscultation Findings (anterior/posterior/lateral):Inspects the thorax (posterior, lateral, anterior) with client sitting. Palpates posterior chest wall for chest expansion 1 Auscultates breath sounds – posterior chest 2 Auscultates breath sounds – anterior chest 2 Auscultates breath sounds – lateral chest walls 8 pts Heart: Auscultation Findings (all valve areas):Auscultates heart sounds in all valve areas using diaphragm of stethoscope (aortic, pulmonic, tricuspid, mitral) 2 Auscultates heart sounds in all valve areas using bell of stethoscope (aortic, pulmonic, tricuspid, mitral) 8 pts Abdomen Appearance: Auscultation Findings (4 quadrants): Palpation Findings (4 quadrants):Inspects abdomen 1 Auscultates the four quadrants with diaphragm of stethoscope 2 Performs light palpation in the four quadrants 6 pts Lower Extremities General Appearance and Condition: Dorsalis Pedis: Posterior Tibialis: Edema: Capillary Refill: Palpates posterior tibial pulses 1 Palpates dorsalis pedis pulses 1 Assess capillary refill (toes) 1 Assess for edema 5 pts Sensory Light Touch (arms): Light Touch (legs): Assess light touch using soft and sharp (on arms and legs) 2 pts Cerebellar Gait: Romberg: Gait: normal (toward & away) and tandem (heel-to-toe) 2 Romberg Test 2 pts Deep Tendon Reflexes Patellar: 1 pts Format Spelling (3) Appropriate Use of Medical Terminology (3) Attention to bilateral findings (4) 10 pts Total Points: 100

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