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Physical Assessment Documentation Form (PADF) - Directions This form will guide you through completing the video and documentation of EEM1 0919. The Assessment Area column tells you which assessment techniques to perform in your video, what to say, and in what position the patient should be during that assessment. The General Survey is only to be documented and not performed in the video. You are encouraged to use this form in the video with you. Assessment findings will be documented by checkmarks or free-text or a drop-down menu in the Assessment Findings column. If your patient has an abnormal finding, you may use the charting by exception area in the right-hand column to provide additional information. Please note that each individual assessment technique must be verbalized in the video prior to you performing it. Simply visualizing your actions does not indicate what is being assessed. Be sure to verbalize what you are going to do and what you are assessing for. A complete head-to-toe assessment video is required, that includes an unobstructed view of each of the assessments, in which the student provides clear verbalization of each step, and demonstrates correct and complete assessment techniques for the minimum of each section as outlined in the rubric. This PADF should be filled out in its entirety based on your patient assessment, including an analysis of findings at the end of the document. Please ensure you select the “Save Progress” button to ensure your progress throughout completing the form is saved and to avoid losing any information. Once you finish filling out this PADF, the last page will allow to you “Download as a PDF.” Save the PDF to your computer so you are able to upload it through your Course of Study with the other required components. For evaluation, remember to include the completed PADF PDF document, a functional Panopto link, and a complete patient consent with a handwritten signature. Required equipment: A real, working stethoscope is required for all auscultation areas. Props may be utilized for items such as BP cuff, pen light, sensation tools, tongue blade, and deep tendon reflex hammer. A watch or timer of some sort should be used for timing certain techniques.

Physical Assessment Documentation Form (PADF) - General Survey Student Name *

Natalie Otten

Please document your observations in the Assessment Findings column. There is no need to discuss these observations during your video. Patient appears to be stated age Yes ▾ Level of Consciousness To Nutritional Status Posture & Position Physical Deformities Mobility Facial Expression Mood & Affect Speech Hearing Personal Hygiene

☑ Alert ☑ Oriented ☑ Person ☑ Place ☑ Time ☑ Well-developed ☐ Poor ☑ Upright ☐ Poor ☐ Present ☑ Not Present ☐ Limited ☑ Unlimited ☑ Appropriate for situation ☐ Not appropriate for situation ☐ Flat ☑ Appropriate ☐ Heightened ☑ Clear ☐ Unclear ☐ Appropriate ☐ Not appropriate ☐ Difficult ☑ Not difficult ☑ Clean ☐ Dirty ☐ Kempt ☐ Un-kempt

Charting by exception — Narrative report of abnormal findings for General Survey section

Physical Assessment Documentation Form (PADF) - Section 1 (minimum 9 out of 11 points required) Measurement and vital signs (2) - Begin in seated position Ask height & weight Height

6'2

ft/In

Weight

225

BMI

28.9

Lb

Take the vital signs: pulse, respirations, blood pressure, and pain level Radial Pulse 78

☑ Regular ☐ Irregular

Respirations 18 Respiratory effort

☐ Deep

☐ Shallow ☐ Labored ☑ Unlabored

effortless

Blood Pressure 128/68 Pain (0-10)

☑ Sitting

☐ Lying

☐ Prop used, not assessed

Description of pain element

0 Skin (7) Hands and nails Hands Swelling

No

Moist

No

Dry

No

Ridges

No

Clubbing

No

Yellow

No

Thick

No

Left

< 2 Sec

Right

< 2 Sec

Nails

Capillary refill

Color and pigmentation Any Lesions/Sores Temperature Moisture Texture Turgor

☐ Pallor ☐ Erythema ☐ Cyanosis ☐ Jaundice ☑ Consistent with ethnic background No

☑ Warm ☐ Cool ☑ Dry ☐ Diaphoretic ☐ Moist ☑ Smooth ☐ Firm ☐ Even ☐ Tenting ☑ Non-tenting

Head and face (2) Scalp, hair, cranium Face (cranial nerve VII)

☑ Normocephalic ☑ No lesions ☑ No lumps ☑ No scaling ☑ No tenderness ☐ Evidence of trauma ☑ Symmetric ☑ No weakness ☐ No involuntary movements

Charting by exception — Narrative report of abnormal findings for Section 1

Physical Assessment Documentation Form (PADF) - Section 2 (minimum 16 out of 19 points required) Eyes (6) External structures - Eyelids, eyelashes, eyebrows Eyes

☐ Ptosis ☐ Lid lag ☐ Discharge ☐ Crusting ☑ Even hair distribution ☑ Eyebrows symmetric ☑ Eyes symmetric ☐ Jaundice ☐ Lesions or redness Sclera color white

Pupil - size, shape, light reflex, convergence

(L) 4

mm At rest

(R) 4 (L) 2

mm At rest mm Constricted

(R) 2 mm Constricted ☑ Pupils Equal ☑ Pupils Round ☑ Pupils reactive to light ☑ Pupils accommodating Visual fields (cranial nerve II) - Confrontation

☑ Full by confrontation Abnormality Select an option

Extraocular muscles (cranial nerves III, IV, VI)

☑ Extraocular eye muscles intact ☐ Nystagmus ☐ Strabismus

Corneal light reflex

☑ Symmetric ☐ Present

Ears (3) External ear Subjective reports

☑ Intact without lesions ☐ No tenderness ☐ No drainage noted ☑ Intact without lesions ☐ No tenderness ☐ No drainage noted ☐ Tenderness ☐ Earaches reported ☐ Tinnitus ☐ Vertigo ☑ None

Left Right

Hearing aids (L) Hearing Aid

No

(R) Hearing Aid

No

Nose (2) External nose Patency of nostrils

☑ Symmetry ☐ Discharge ☐ Redness ☑ (L) nostril patent ☑ (R) nostril patent ☐ History of epistaxis

Mouth and throat (5) Lips and buccal mucosa

Lips Mucosa

☑ Moist ☐ Dry ☑ Pink ☐ Red ☐ Pale ☑ Moist ☐ Dry ☑ Pink ☐ Red ☐ Pale

Teeth 2

Brushes teeth Flosses daily

x per day

No

Date of last dental visit

22-Jul-20

☐ Discolored ☐ Presence of caries

Gums Tongue Uvula (cranial nerves IX, X)

Color of gingiva

pink

Moist

Yes

☑ Red ☐ Swollen ☐ Bleed easily ☑ Moist ☐ Dry ☑ Pink ☐ Red ☐ Pale ☑ Gag reflex present ☑ Uvula intact ☑ Uvula midline

Neck (3) Carotid pulse Trachea ROM and muscle strength (cranial nerve XI)

☑ Palpable bilaterally (one at a time) ☑ Midline ☐ Deviated ☑ Full ROM ☐ Limited ROM ☑ Able to shrug against resistance ☐ Unable to shrug against resistance

Charting by exception — Narrative report of abnormal findings for Section 2

Physical Assessment Documentation Form (PADF) - Section 3 (minimum 10 out of 12 points required) Posterior chest and lungs (4) Thoracic cage configuration a. Shape and configuration b. Symmetric expansion

☑ Symmetric expansion ☐ Barrel chested ☐ Use of accessory muscles ☐ Pectus excavatum

Tactile fremitus, lumps, tenderness (L)

☐ Tactile fremitus ☐ Lumps

☐ Tenderness

☑ Not present

(R)

☐ Tactile fremitus ☐ Lumps

☐ Tenderness

☑ Not present

Costovertebral (CVA) angle tenderness

☐ Tender ☑ Non-Tender

Posterior Breath sounds

RUL RML RLL LUL LLL

Vesicular

Diminished

Rhonchi

Crackles

Wheezes

☑ ☑ ☑ ☑ ☑

☐ ☐ ☐ ☐ ☐

☐ ☐ ☐ ☐ ☐

☐ ☐ ☐ ☐ ☐

☐ ☐ ☐ ☐ ☐

Anterior chest and lungs (2) Tactile fremitus, lumps, tenderness Left Right

☐ Tactile fremitus ☐ Lumps

☐ Tenderness

☑ Not present

☐ Tactile fremitus ☐ Lumps

☐ Tenderness

☑ Not present

Anterior Breath Sounds

RUL RML RLL LUL LLL

Vesicular

Diminished

Rhonchi

Crackles

Wheezes

☑ ☑ ☑ ☑ ☑

☐ ☐ ☐ ☐ ☐

☐ ☐ ☐ ☐ ☐

☐ ☐ ☐ ☐ ☐

☐ ☐ ☐ ☐ ☐

Heart (3) Apical impulse (PMI) Apical heart rate

Heart sounds

☑ Palpable

☐ Non-palpable

80

rate

☑ Rhythm regular ☐ Rhythm irregular ☑ S1 ☑ S2 ☐ Murmur

Upper extremities (2) ROM and muscle strength

Pulses a. Brachial b. Radial

Left

☑ Full ROM ☐ Limited ROM ☐ Weakness ☐ Equal bilaterally ☐ Strong

Right

☑ Full ROM ☐ Limited ROM ☐ Weakness ☐ Equal bilaterally ☐ Strong

0 Absent 1+ Weak 2+ Normal 3+ Increased, full, bounding (L) Brachial

2+

(R) Brachial

2+

(L) Radial

2+

(R) Radial

2+

Neck vessels (1) - Move to supine position Presence of jugular venous distension

☑ Not Present ☐ Present

Charting by exception — Narrative report of abnormal findings for Section 3

Physical Assessment Documentation Form (PADF) - Section 4 (minimum 16 out of 19 points required) Abdomen (4)

☐ Flat ☑ Rounded ☐ Scaphoid ☐ Protuberant ☑ Symmetric☐ Mass ☐ Bulging ☐ Pulsations Umbilicus: ☑ Midline ☐ Inverted ☐ Everted

Contour, symmetry, umbilicus, and pulsations

Bowel sounds (x4 Quadrants)

Normoactive Hyperactive Hypoactive Absent

RUQ

RLQ

LUQ

LLQ

☑ ☐ ☐ ☐

☑ ☐ ☐ ☐

☑ ☐ ☐ ☐

☑ ☐ ☐ ☐

Light and deep palpation of 4 quadrants Light

RLQ RUQ LUQ LLQ

Soft

No mass

No tenderness

☑ ☑ ☑ ☑

☑ ☑ ☑ ☑

☑ ☑ ☑ ☑

Soft

No mass

No tenderness

☑ ☑ ☑ ☑

☑ ☑ ☑ ☑

☑ ☑ ☑ ☑

Deep

RLQ RUQ LUQ LLQ

Percussion x 4 quadrants RLQ RUQ LUQ LLQ

Tympany

Dullness

☑ ☑ ☑ ☑

☐ ☐ ☐ ☐

Lower extremities (4) Symmetry, skin characteristics, hair distribution

☑ Symmertical ☐ Non-symmetrical ☐ Pallor ☐ Erythema ☐ Cyanosis ☐ Ulcers ☐ Lesions ☐ Varicosities ☑ Hair evenly distributed

Toes a. Capillary refill

☐ Clubbing Capillary refill: (L)

< 1 Sec (R)

Temperature, pretibial edema

☐ Left Cool ☑ Left Warm 0 No edema 1+ Mild pitting 2+ Moderate pitting 3+ Deep pitting 4+ Very deep pitting

☐ Right ☑ Right

Pretibial Edema (L): 0 Pretibial Edema (R): 0 Pulses 1. 2. 3. 4.

Femoral Popliteal Posterior tibial Dorsalis pedis

0 Absent 1+ Weak 2+ Normal 3+ Increased, full, bounding (L) Femoral

2+

(R) Femoral

2+

(L) Popliteal

2+

(R) Popliteal

2+

(L) Posterior tibial

2+

(R) Posterior tibial

2+

(L) Dorsalis pedis

2+

(R) Dorsalis pedis

2+

Musculoskeletal/neurologic (2) Hip - ROM

☐ Pain ☐ Tenderness ☐ Crepitation Flexion: 90

approximate degrees

Abduction: 45

approximate degrees

Internal Rotation: approximate degrees 45 External Rotation: approximate degrees 45 Ankles and feet a. ROM

☐ Swelling ☐ Pain ☐ Tenderness ☐ Ulcers ☐ Redness ☐ Edema

b. Strength

Plantar Flexion: (L) Strong (R) Strong Dorsiflexion: (L) Strong (R) Strong Eversion: (L) Strong (R) Strong

Musculoskeletal/neurologic (2) - return to sitting position

Bilateral deep tendon reflexes a. Biceps b. Triceps c. Brachioradialis d. Patellar e. Achilles

0 No response 1+ Diminished, low normal 2+ Average, normal 3+ Brisker than average 4+ Very brisk, hyperactive with clonus a. Biceps

2+

b. Triceps

2+

c. Brachioradialis

2+

d. Patellar

2+

e. Achilles

2+

Present Sensation a. Face b. Arms c. Hands d. Legs e. Feet

Face

Yes

Arms

Yes

Hands Yes Legs

Yes

Feet

Yes

Spine/neurologic (5) - Have patient stand Touch toes ROM of spine Shallow knee bend Walk across room (heel to toe)

☑ Full ROM ☐ Limited ROM ☐ Pain with ROM ☑ Full ROM ☐ Limited ROM ☐ Pain with ROM ☑ Full ROM ☐ Limited ROM ☐ Pain with ROM ☑ Appropriate coordination ☐ Poor coordination

Walk on tiptoes, then walk on heels

☑ Appropriate coordination ☐ Poor coordination

Presentation (2)

☑ Advises follow-up with primary care provider

☑ Thanks patient

Charting by exception — Narrative report of abnormal findings for Section 4

Physical Assessment Documentation Form (PADF) - Analysis of findings Analysis of Findings: Provide a brief (1-2 paragraph) report as you would when you give report to another nurse assuming care of this patient. Patient appears stated age and in good health condition and had no medical complaints during examination. Patient had appropriate mood and effect and was oriented x 4, answering questions appropriately. Vital signs were within normal range, breathing effortless and heart rate regular. S1 and S2 noted, no murmurs detected. Lung sounds were clear in all fields to auscultation. Bowel sounds normoactive in all four quadrants. Patient denied pain during assessment when evaluating all body systems. No abnormal findings at todays assessment. Patient advised to make dental appointment as date of last exam in unknown, and to follow up with primary care provider. Note: If you make a mistake while recording, you may either verbalize your correction (if appropriate) and redo the technique prior to ending the recording, or you may record an addendum. Both videos would then need to be submitted for evaluation purposes. If you submit your video, it is evaluated, and a section is determined to not meet the minimum score requirement, that section must be re-recorded. You are only required to re-record any section that fails, not your entire video. Upon evaluation of your resubmission, all assessment techniques in that section will be re-evaluated for competency, regardless of whether or not they were performed correctly during the previous video. A new patient consent and a PADF that corresponds to the new video must also be included with the resubmission....