Professional Documents
Culture Documents
Patient Name:
MRN:
Date:
SYSTEM REVIEW
Eyes:
NSF
Blurred Vision
Yes
Near Sighted
Inflammation
Yes
Drainage
Yes
Other:
NO Glasses/Contacts
Yes
NO
Far Sighted
Astigmatism
NO Itching
Yes
NO
NO Color/Amt:____________________
Physical Findings:
(Describe and graph all abnormalities by number on Body Chart)
1. Abnormal Color:
2. Body Piercing :
3. Bruises:
Ears:
NSF
HOH:
Dizziness
Pain
Other:
Nose:
NSF
Congestion
Nosebleeds
Pain
Other:
Yes
Yes
Yes
NO (R) (L)
Deaf:
NO Balance Problems
NO
Drainage
Yes
Yes
Yes
NO
NO
NO
4. Decubitus:
5. Dryness:
6. Incisions:
7. Lacerations:
Yes
Yes
Yes
Mouth:
NSF
Bleeding Gums
Sense of Taste
Dental Hygene
Other:
NO Sinus Problems
Yes
NO
NO Frequency: _______________________
NO Drainage: ________________________
8. Lesions:
9. :Rashes:
10. Scars:
11. Skin Tear:
Yes
Yes
Good
Throat/Neck:
NSF
Sore Throat
Yes
Swollen Glands
Yes
Stiffness
Yes
Other:
NO Lesions
Yes
NO
Fair
Poor
NO Hoarseness
NO
Lumps
NO
Pain
Yes
Yes
Yes
NO
12. Tattoos:
13. Vascular Access:
14. Other:
NO
NO
NO
Neurological:
NSF
LOC:
Alert
Confused
Sedated
Somnolent
Speech:
Clear
Slurred
Aphasic
Dysphasia
PEARL
Yes
NO
Grip Equal
Yes
NO
Cooperative
Yes
NO ________________________________
Oriented to: Person
Place
Time
Other:
Respiratory:
NSF
Dyspnea
Yes
NO
w/ Activity
At Rest
Retractions
Cough
Yes
NO
non-Productive
Productive
Hemoptysis
Yes
NO Cyanosis
Yes
NO
Lung Sounds: ____________________________________________
Other:
Cardiovascular:
NSF
Heart Rate
Reg
Irreg
Brady
Tachy
Pulses
Equal Bilat, _____________________________________
Edema Location: ________________________________________
Pitting
None-pitting
JVD
Yes
NO
Pain
Yes
NO ______________________________________
Other:
Vascular Access:
AVF:
Mature
YES
NO
YES
NO
YES
NO
Signature: