Last updated on October 7th, 2023 at 12:25 pm
The purpose of this assignment is to demonstrate the ability to document the findings of an objective head to toe assessment and identify abnormal findings.
- 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.
- 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.
- Chapter 5: SOAP Notes: The subjective and objective portion only
- Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from
- Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30.
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