Download physical assessment documentation guide

N155 PHYSICAL ASSESSMENT DOCUMENTATION GUIDE
Student____________________________
Date ________________
Client/Patient ___________________________Age ________Sex__________
General Survey
Physical Appearance
Overall hygiene and grooming
Any apparent signs of distress
Skin Color
Body Structure
Stature
Nutrition
Symmetry
Posture/Position
Body Build
Mobility
Gait
Range of Motion
Involuntary Movement
Behavior
Mood and affect/
Facial expressions (appropriate for situation)
Dress
Level of consciousness
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. Write neatly
as if writing in a chart
PHYSICAL ASSESSMENT DOCUMENTATION GUIDE – SKIN, HAIR AND NAILS
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). Write
Neatly.