

Objective Data Collection: 8 of 8 (100.0%)
Correct
Partially correct
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Incorrect
Missed
Inspected General Appearance
1 of 1 point
Clothing (1/3 point)
– Clean clothing, appropriate for age, fit, season, and occasion
– Dirty, disheveled, or inappropriate to age, fit, season, or occasion
Odor (1/3 point)
– Odor detected
– No odor detected
Posture (1/3 point)
– Upright posture without tension or rigidity
– Bent or hunched posture, tension, or rigidity
Inspect Head
1 of 1 point
Inspect Skin Head (1/1 point)
– Benign
– Abrasions
– Dandruff
– Erythema
– Lice
– Macules
– Papules
– Pustules
– Skin Breakdown
– Vesicles
Inspect Arms
1 of 1 point
Inspect Skin Arms (1/1 point)
– Benign
– Abrasions
– Erythema
– Lice
– Macules
– Papules
– Pustules
– Skin Breakdown
– Vesicles
Inspect Torso
1 of 1 point
Inspect Skin Torso (1/1 point)
– Benign
– Abrasion
– Erythema
– Lice
– Macules
– Papules
– Pustule
– Skin Breakdown
– Vesicles
Inspect Legs
1 of 1 point
Inspect Skin Legs (1/1 point)
– Benign
– Abrasions
– Erythema
– Lice
– Macules
– Papules
– Pustules
– Skin Breakdown
– Vesicles
Auscultate Heart
1 of 1 point
Heart Sounds (1/4 point)
– S1 and S2 audible
– S1, S2, and S3 audible
– S1, S2, and S4 audible
– S1, S2, S3, and S4 audible
Extra Heart Sounds (1/4 point)
– No extra heart sounds
– Gallups
– Murmur
– Friction rubs
Rate (1/4 point)
– Regular rate
– Irregular rate
Rhythm (1/4 point)
– Regular rhythm
– Irregular rhythm
Auscultate Lungs
1 of 1 point
Appearance (1/4 point)
– Accessory muscle use
– No distress
Symmetry (1/4 point)
– Symmetrical chest rise and fall
– Asymmetrical chest rise and fall
Breath Sounds (1/4 point)
– Clear in all areas
– Diminished in some areas
– Absent in some areas
Adventitious Sounds (1/4 point)
– No adventitious sounds
– Wheezing
– Crackles
– Stridor
– Rhonchi
Palpate Rash
1 of 1 point
Palpated Rash (1/2 point)
– Tenderness with palpation
– Non-tender with palpation
Temperature (1/2 point)
– Cold
– Warm
– Hot
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