0 pts
7 pts
9 pts
10 pts
(N/A)
Includes all pertinent objective data.
Provides clearly written explanation for patient appointment
How they got to this point in their health? What Signs and Symptoms? What tests did they have completed? How many times have they been hospitalized? What are the patients concerns?
General Health Accidents or Injuries Chronic Illnesses Hospitalizations Operations cardiothoracic surgery: Immunizations: Last Health Examinations: Current Medications/Supplments Allergies
Ask patient questions related to each system and get the patient's impression of their health
List the values and normals values. If no labs are available states indicate.
Includes CT scans, MRI's or other radiographs.
Summarizes all the history, physical, and subjective, objective information
Ask the client how they view themselves, what they do to cope with stress, how they sleep, exercise.
Ask the client about their view of themselves, assess if they are functionally dependent, and if their behavior is appropriate
Assesses all systems using Inspection, Palpation, Auscultation.