Documentation Of Complete Head To Toe Physical Assessment

module 11 content

You completed your full head-to-toe assessment skills demonstration last week and now will document your results. Continue to document only the objective findings for this section without bias or explanation. Remember if you can’t feel something then it is “nonpalpable,” if you can’t hear something just state they were not heard such as no bowel sounds heard (unless you listened for the full five minutes which we wouldn’t want to do for our purposes – then you could document absent bowel sounds). Be descriptive if necessary but at the same time be brief.

p.s use my provided word doc I uploaded to answer the above assesment.

Complete Head to Toe Assessment

 

 

General Survey (mental status & appearance):

 

 

Head:

 

Eyes:

 

 

Ears:

 

 

Nose:

 

 

Mouth:

 

 

Neck:

 

 

Thorax/Lung/Back Assessment:

 

 

Cardiac/Central Vessel Assessment:

 

 

Gastrointestinal:

 

 

 

Genitourinary:

 

 

 

Musculoskeletal/Neuro/PV Assessment:

 

 

 

Other: (Add any additional findings here)