MindMap Gallery Documenting the examination

Documenting the examination

Documenting a physical examination is an important aspect of healthcare practice, providing a detailed record of the patient's current health status and aiding in the continuity of care. Here are the key components to consider when documenting a physical examination.

Edited at 2022-09-16 15:15:35

Cheyenne Arianna Manguiran

Documenting the examination

Cheyenne Arianna Manguiran

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Outline

DOCUMENTING THE EXAMINATION

HISTORY

DEMOGRAPHIC INFORMATION

patient's name

address

admission date

date of birth

sex

dominant hand

race

ethnicity

language

educational attainment

advanced directive preferences

referral source

reasons for referral to therapy

CURRENT CONDITIONS/CHIEF COMPLAINTS

onset date of problem

any incident that caused/contributed to the onset of the problem

prior history of similar problems

how pt. is caring for the problem

what makes the problem better

what makes the problem worse

any practitioner the pt. is seeing for the problem

PATIENT GOALS

pt. and family goals

PRIOR LEVEL OF FUNCTION

level of function prior to the most recent onset of current condition

SOCIAL Hx

cultural and religious beliefs

available social and physical supports

availability of a caregiver

EMPLOTMENT STATUS

full time

part time

work from home

onsite working

retired

student

LIVING ENVIRONMENT

assistive devices and equipment

type of residence

community services

GENERAL HEALTH STATUS

patient's rating of health

experienced any major life changes during the preceding year

SOCIAL/HEALTH HABITS

alcohol and tobacco use

exercise habits

FAMILY HEALTH Hx

heart disease

hypertension

stroke

diabetes

cancer

arthritis

osteoporosis

PATIENT'S MEDICAL/SURGICAL Hx

information about medical and surgical history of the patient

FUNCTIONAL STATUS

bed mobility

transfers

gait

self-care

home management

community

working activities

MEDICATION

current medication the patient is taking

GROWTH AND DEVELOPMENT

most applicable to pediatric patients

OTHER CLINICAL TESTS

TEST & MEASURES