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.

 Course Competency:

• 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.

Instructions:

 Content:

• 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.

Format:

• Standard American English (correct grammar, punctuation, etc.)

Resources:

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