• Perform all elements identified by a bullet
• Document every element in a box with a shaded border
• Document at least one element in each box with an unshaded border

Constitutional


*All elements must be documented.

• Measurement of any three of the following seven vital signs:
  • Sitting or standing blood pressure
  • Supine blood pressure
  • Pulse rate and regularity
  • Respiration
  • Temperature
  • Height
  • Weight (may be measured and recorded by ancillary staff)
• General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)

Neck

• Examination of neck (e.g., masses, overall appearance, mmetry, tracheal position, crepitus)
• Examination of thyroid (e.g., enlargement, tenderness, mass)

Respiratory

• Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
• Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)

• Auscultation of heart with notation of abnormal sounds and murmurs
• Examination of peripheral vascular system by observation (e.g., swelling, varicosities) and palpation (e.g., pulses, temperature, edema, tenderness)

• Examination of abdomen with notation of presence of masses or tenderness
• Examination for presence or absence of hernia
• Examination of liver and spleen
• Obtain stool sample for occult blood test when indicated

• Inspection of anus and perineum 

• Scrotum (e.g., lesions, cysts, rashes)
• Epididymides (e.g., size, symmetry, masses)
• Testes (e.g., size, symmetry, masses)
• Urethral meatus (e.g., size, location, lesions, discharge)
• Penis (e.g., lesions, presence or absence of foreskin, foreskin retractability, plaque, masses, scarring, deformities) 

• Prostate gland (e.g., size, symmetry, nodularity, tenderness)
• Seminal vesicles (e.g., symmetry, tenderness, masses, enlargement)
• Sphincter tone, presence of hemorrhoids, rectal masses

Female:
Includes at least seven of the following eleven elements identified by bullets:

• Inspection and palpation of breasts (e.g., masses or lumps, tenderness, symmetry, nipple discharge)
• Digital rectal examination including sphincter tone, presence of hemorrhoids, rectal masses

Pelvic examination (with or without specimen collection for smears and cultures) including:

• External genitalia (e.g., general appearance, hair distribution, lesions)
• Urethral meatus (e.g., size, location, lesions, prolapse)
• Urethra (e.g., masses, tenderness, scarring)
• Bladder (e.g., fullness, masses, tenderness)
• Vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
• Cervix (e.g., general appearance, lesions, discharge)
• Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)
• Adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)
• Anus and perineum

• Palpation of lymph nodes in neck, axillae, groin and/or other location

• Inspection and/or palpation of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)

• Orientation (e.g., time, place and person) 
• Mood and affect (e.g., depression, anxiety, agitation)