| System/Body Area |
Elements of Examination
|
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)
|
Ears, Nose, Mouth and Throat
*All elements must be documented. |
- Inspection of nasal mucosa, septum and turbinates
- Inspection of teeth and gums
- Examination of oropharynx (e.g., oral mucosa, hard and soft palates, tongue, tonsils and posterior pharynx)
|
Neck
*All elements
must be documented. |
- Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
- Examination of thyroid (e.g., enlargement, tenderness, mass)
- Examination of jugular veins (e.g., distension; a, v or cannon a waves)
|
Respiratory
*All elements must be documented. |
- Inspection of chest with notation of symmetry and expansion
- Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
- Percussion of chest (e.g., dullness, flatness, hyperresonance)
- Palpation of chest (e.g., tactile fremitus)
- Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)
|
Cardiovascular
*All elements must be documented. |
- Auscultation of heart including sounds, abnormal sounds and murmurs
- Examination of peripheral vascular system by observation (e.g., swelling, varicosities) and palpation (e.g., pulses, temperature, edema, tenderness)
|
Gastrointestinal (Abdomen)
*All elements must be documented. |
- Examination of abdomen with notation of presence of masses or tenderness
- Examination of liver and spleen
|
| Lymphatic |
- Palpation of lymph nodes in neck, axillae, groin and/or other location
|
| Musculoskeletal |
- Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements
- Examination of gait and station
|
| Extremities |
- Inspection and palpation of digits and nails (e.g., clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)
|
| Skin |
- Inspection and/or palpation of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
|
Neurological/
Psychiatric |
Brief assessment of mental status including:
- Orientation to time, place and person
- Mood and affect (e.g., depression, anxiety, agitation)
|