Patient Encounter Form Page 4
ADVERTISEMENT
1
2
3
4
5
6
7*Cervix
Normal
Absent
Abnormal
*Uterus
Normal
Absent
Abnormal
*Adnexa
Normal
Absent
Abnormal
*Anus/Perineum
Normal
Abnormal
*Bimanual &
Normal
Abnormal
Rectovaginal
LYMPHATICS:
*Neck--Supraclavicular
Normal
Abnormal
*Axillae
Normal
Abnormal
*Groin
Normal
Abnormal
*Other
Normal
Abnormal
MUSCULOSKELETAL:
*Gait
Normal
Abnormal
*Digits /nails
Normal
Abnormal
Examination of joints, bones, and muscles of (1) or more of the following areas: (1) Head/neck
(2) Spine, ribs, pelvis (3) RUE (4) LUE (5) RLE (6) LLE: The exam of a given area includes:
*Inspection / palpation or presence of misalignment, asymmetry, crepitation, defects, effusions
*ROM, pain, contracture
*Dislocations, subluxation, or laxity
*Muscle strength or tone, atrophy, abnormal movements
SKIN:
*Inspection Skin/SQ tissue
Normal
Abnormal
*Palpation Skin/SQ tissue
Normal
Abnormal
Neurologic:
*Cranial Nerves
Normal
Abnormal
*Deep Tendon Reflex
Normal
Abnormal
*Sensation
Normal
Abnormal
Mental Status:
*Oriented: Person, Place, Time
Yes
No ________________________
*Recent and remote memory
Normal
Abnormal
*Affect
Normal
Abnormal
4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical