Module 11 Lab Assignment – Documentation Of 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.
- 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.
- Standard American English (correct grammar, punctuation, etc.)
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. Retrieved from