You completed your full head-to-toe assessment skills demonstration and now will document your results. Document only the objective findings for this assignment 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.
Title:
Documentation of the complete head to toe physical assessment.
Purpose of Assignment:
To demonstrate the ability to document the findings of an objective head to toe assessment and
identify abnormal findings.
Course Competency:
Demonstrate physical examination skills of the skin, hair, nails, and musculoskeletal system.
Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary
systems.
Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and
regional lymphatics.
Apply assessment techniques for the neurological and respiratory systems.
Select appropriate physical examination skills for the cardiovascular and peripheral vascular
systems.
Instructions:
Content:
• Objective findings including short descriptive paragraph of findings for each section.
• Actual or potential risk factors for the client based on the assessment findings with
description or reason for selection of them.
Format:
• Standard American English (correct grammar, punctuation, etc.)
Resources:
