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The document is a physical examination form for students in Collingswood Schools, collecting personal information, medical history, and details about the student's health assessment. It includes sections for height, weight, vision, hearing, blood pressure, and various health checks. The form also addresses immunization records and clearance for physical education participation.

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How to document a normal neuro exam?

Documentation of a basic, normal neuro exam should look something along the lines of the following: The patient is alert and oriented to person, place, and time with normal speech. No motor deficits are noted, with muscle strength 5/5 bilaterally. Sensation is intact bilaterally.

How to document a normal heent exam?

Sample Normal Exam Documentation Head The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Eyes Visual acuity is intact. Ears The pinna, tragus, and ear canal are non-tender and without swelling. Nose Nasal mucosa is pink and moist.

What are the 4 components of a physical exam?

Inspection (looking at the body) Palpation (feeling the body with fingers or hands) Auscultation (listening to sounds, usually with a stethoscope) Percussion (producing sounds, usually by tapping on specific areas of the body)

How to document strength in extremities in nursing?

A common method of evaluating muscle strength is the Medical Research Council Manual Muscle Testing Scale. This method involves testing key muscles from the upper and lower extremities against gravity and the examiners resistance and grading the patients strength on a 0 to 5 scale.

What is an example of a physical exam?

In general, the standard physical exam typically includes: Vital signs: blood pressure, breathing rate, pulse rate, temperature, height, and weight. Vision acuity: testing the sharpness or clarity of vision from a distance. Head, eyes, ears, nose and throat exam: inspection, palpation, and testing, as appropriate.

normal physical exam template

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How to document an extremity exam?

Documentation of a basic, normal extremity exam should look something along the lines of the following: Extremities are atraumatic in appearance without tenderness or deformity. Extremities are without swelling or erythema. Full range of motion is noted to all joints.

What to document for musculoskeletal assessment?

Observe the patient using their arms, legs, gait, ability to sit and stand, and posture. Note symmetry; compare each side of the body. Inspect overall size, bony , and alignment of muscles and joints. Observe coordination and muscle function and note balance, limping, presence of deformity, or shuffling.