p h y s i c a l a s s e s s m e n t d o c u m e n t a t i o n- cerritos（l p h y s c a e年代年代m e n t d o c u m e n t t i o n -喜瑞）.docVIP

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p h y s i c a l a s s e s s m e n t d o c u m e n t a t i o n- cerritos（l p h y s c a e年代年代m e n t d o c u m e n t t i o n -喜瑞）.doc

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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__________ Asses