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Physical Assessment Paper ________________ GUIDELINES FOR WRITTEN PHYSICAL EVALUATION PAPERS ADULT EVALUATION 1. Patient Identification Age/DOB; Race; Sex; Religion; Occupation 2. Past Medical History (PMH)- (5 POINTS) Illnesses; Surgeries/Procedures; Childhood Illnesses; Trauma; Most Recent Physical Examination; LMP 3. Medications- (5 POINTS) Prescription and OTC dose and frequency 4. Allergies- (2 POINTS) Medication, Food and Environmental clarify what kind of reaction 5. Social History- (3 POINT) Tobacco; Alcohol; Caffeine; Recreational Drug Use 6. Immunizations and Travel- (1 POINT) 7. Family History (FHx)- (4 POINTS) Marital Status; Parents (living, dead, cause of death); family illnesses 8. Review of Systems: (this is told by the patient during the interview)- (15 POINTS) General; Head, Ears, Eyes, Nose, Throat; Pulmonary; Cardiac; Gastrointestinal; Genitourinary; Musculoskeletal; Vascular; Endocrine; Blood; Integumentary; Psychological 9. Physical Examination: (this is what the examiner observes)- (15 POINTS) General Appearance; VS; HEENT; Neck; Lymph Nodes; Breast; Respiratory/Thorax; Cardiac; Abdomen; GU (not required for this course- write EXAM DEFERRED); Rectal(not required for this course-write EXAM DEFERRED); Vascular/Pulse; Musculoskeletal; Neurological (including cranial nerves I-XII, Motor, Coordination, Sensory, Reflexes) _____________ APA format and reference page

Date Posted: 25/08/2017
Category: General
Due Date: 11/09/2017
Instruction
Physical Assessment Paper
________________

GUIDELINES FOR WRITTEN PHYSICAL EVALUATION PAPERS ADULT EVALUATION
1. Patient Identification
Age/DOB; Race; Sex; Religion; Occupation


2. Past Medical History (PMH)- (5 POINTS)
Illnesses; Surgeries/Procedures; Childhood Illnesses; Trauma; Most Recent Physical Examination;
LMP


3. Medications- (5 POINTS)
Prescription and OTC dose and frequency 4. Allergies- (2 POINTS)
Medication, Food and Environmental clarify what kind of reaction 5. Social History- (3 POINT)
Tobacco; Alcohol; Caffeine; Recreational Drug Use


6. Immunizations and Travel- (1 POINT)


7. Family History (FHx)- (4 POINTS)
Marital Status; Parents (living, dead, cause of death); family illnesses


8. Review of Systems: (this is told by the patient during the interview)- (15 POINTS)
General; Head, Ears, Eyes, Nose, Throat; Pulmonary; Cardiac; Gastrointestinal; Genitourinary; Musculoskeletal; Vascular; Endocrine; Blood; Integumentary; Psychological


9. Physical Examination: (this is what the examiner observes)- (15 POINTS)
General Appearance; VS; HEENT; Neck; Lymph Nodes; Breast; Respiratory/Thorax; Cardiac; Abdomen; GU (not required for this course- write EXAM DEFERRED); Rectal(not required for this course-write EXAM DEFERRED); Vascular/Pulse; Musculoskeletal; Neurological (including cranial nerves I-XII, Motor, Coordination, Sensory, Reflexes)

_____________


APA format and reference page

A great example is attached to refer to.
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