Criteria

4 points

3 points

2 points

0 points

Total Points

Part I: Physical Assessment

All components of the physical assessment are present.

Most of the information is provided with all areas addressed. No more than 3 missing areas.

No more than 6 of the assessment areas are lacking information.

Assessment information not provided

Part II: History & Physical

Information is complete and accurate; All areas of the section are addressed.

Most of the information is provided with all areas addressed. No more than 3 missing areas.

No more than 6 of the history & physical areas are lacking information.

Assessment information not provided

Part III: Medications

Information is complete and accurate; All areas of the section are addressed.

Most of the information is provided with all areas addressed. No more than 3 missing areas.

No more than 6 of the history & physical areas are lacking information.

Assessment information not provided

Part IV:

Diagnostic Studies & Interpretation/Assessment Explanation

Information is complete and accurate; All areas of the section are addressed.

Most of the information is provided with all areas addressed. No more than 3 missing areas.

No more than 6 of the history & physical areas are lacking information.

Assessment information not provided

Part V: Clinical Judgement Measurement Model Table

Information is complete and accurate; All areas of the section are addressed.

Most of the information is provided with all areas addressed. No more than 3 missing areas.

No more than 6 of the history & physical areas are lacking information.

Assessment information not provided

Total points

/20

GENERAL SURVEY

Age___________ Male/Female/Other Body Build: WNL Muscular Obese Thin Cachectic

Height___________ Weight____________ Well-groomed Poorly Groomed

Facial Expression: Content Happy Anxious Sad Angry Flat

NEUROLOGICAL

(LOC) Level of

Consciousness

Alert Awake Lethargic Obtunded Stupor Comatose Confused

Oriented x 4:

If not alert X 4, circle what they are alert to: Person Place Time Situation

Eyes

Unaided sight Glasses Contact lens Blind

Pupils

Equal Round Reactive to light Accommodates List abnormal findings:________________________________________

Pupil reaction: Brisk Sluggish Nonreactive to light

Pupil size: before light ______mm after light ______mm

Ears

Unaided hearing Hard of hearing Deaf Hearing aid Implant

Extremity Strength

Hand grips +1 +2 +3 +4 +5 equal unequal

Foot pushes +1 +2 +3 +4 +5 equal unequal

Pain

Location:

Onset (when did it start):

Provokes (makes it worse):

Palliates (makes it better):

Quality (description):

Radiate: location:

Severity: ___/10

Time: Constant Intermittent

CARDIOVASCULAR

Skin / Mucous Membranes

Normal for Ethnicity Pallor Cyanotic Jaundiced Ruddy Flushed Diaphoretic

Radial and Pedal Pulses

Radial: Right: Strong Weak Thready Absent Left: Strong Weak Thready Absent

Pedal: Right: Strong Weak Thready Absent Left: Strong Weak Thready Absent

Apical Radial Pulses

(2 assessed simultaneously) Equal Pulse Deficit

Capillary Refill

Normal (<3 Sec) ______sec Location:________________

Edema

Absent Present: location +1 +2 +3 +4 Non-Pitting

Heart Rhythm/

Sounds – S1S2

Heart Rhythm: Regular Irregular

Heart Sounds: S1/S2 Murmur Extra Sounds

Sound: Strong Distant

IV

None

Solution_______________ Rate ____ml/hr

Site location (be specific) ______________________________________

Site appearance: WNL Edema Erythema Tender Pallor

Dialysis access: type __________ Thrill Bruit Location:___________ Appearance:____________

RESPIRATORY

Respirations

Pattern: Regular Irregular

Effort: Unlabored Labored Nasal flaring Sternal retraction Intercostal retraction

Chest Expansion: Symmetrical Asymmetrical

Lung Sounds

Anterior : Clear______ Wheezes______ Crackles ______ Rales______ Rhonchi______ Diminished______

Posterior: Clear______ Wheezes______ Crackles ______ Rales______ Rhonchi______ Diminished______

Cough

None Non-productive Productive Sputum: amount color

Oxygen

Room air O2 at_____L/min

Nasal Cannula Oximizer Simple Mask Partial Re-Breather Mask Non-Rebreather Mask

Respiratory Treatments

Incentive Spirometer (IS): ml______ # of times______

Nebulizer:_____________ Inhalers:______________ Flutter Valve:_______________

GASTROINTESTINAL

Oral

Mouth: Teeth Dentures Caries

Swallowing: Gag reflex Dysphagia

Mucous Membranes: intact moist dry pale pink

Abdomen:

Contour: Soft Round Flat Scaphoid Obese

Palpation: Firm Hard Tender Non-Tender Location:

Distention: Nondistended Distended

Bowel Sounds

RLQ Normoactive Hypoactive Hyperactive Absent

RUQ Normoactive Hypoactive Hyperactive Absent

LUQ Normoactive Hypoactive Hyperactive Absent

LLQ Normoactive Hypoactive Hyperactive Absent

NG/ GT/ JT

None

Type of tube _____ patent non-patent

Purpose: Suction Feeding Medication Administration

Type of food: _________ Fluid Flush__________mL

Bowel Movement

Continent Incontinent

Last BM__________ Color Consistency

Ostomy: yes no

Nutrition

Self-feed Needs assistance

Diet___________ % eaten Breakfast_______ Lunch________ NPO_________ if yes, why?___________

Thickened liquids: honey nectar pudding Food Consistency: Regular Mechanical Soft Pureed

Tube Feed: Yes or No

GENITOURINARY

Urine

Continent Incontinent

Urgency Hesitancy Frequency Burning Nocturia

Catheter type _______________ None

Color_________________ Clear Cloudy Sediment Burning Frequency

Intake and Output

PO/Oral/Tube Feed intake____________ mL

IV intake____________ mL

Urine output_________ mL

Other output_________ mL

Fluid restriction ___________mL/day

MUSCULOSKELETAL

ROM

Active ROM: Completed____________ Passive ROM: Completed____________

Mobility

Ambulatory assistance: Independent Gait belt Cane Walker Crutches Wheelchair

Walks: distance frequency tolerance PT OT

Other Musculoskeletal

Cast: Location:

Brace: Type: Location:

Amputation: Location:

Risk for Falls

Bed alarm Chair alarm 1 or 2 Person Transfer Floor mat Side Rails Mechanical Lift Slide Board

INTEGUMENTARY

Appearance

Color: Normal for Ethnicity Pallor Rash Bruise Lesions

Intact

OR

Non-Intact: Location of Non-Intact Areas_____________________________________________________

New Scars: Location _________________________

Dressing change: (describe: location, steps, drainage, wound)

Temperature and Moisture

Temperature: Warm Hot Cool Cold

Moisture: Dry Moist

Incisions/Wound

None

Surgical site – Location Incision Edges: Well-approximated Sutures Staples Steri-strips

Dressing: Dry/intact Non-intact Change: yes no

Drainage: Color Amount___________ Odor_________

Wounds

Location: Wound appearance Tunneling Eschar Slough

Location: Wound appearance Tunneling Eschar Slough