Cognitive Abilities Assessment
- Collecting/Organizing Objective Information
- Mini-Mental State Examination (MMSE)
- Montreal Cognitive Assessment Test (MoCA)
- Mini-Cog
Cerebellar Assessment
- Observe Rapid Alternating Movements (RAM)
- Touch Thumb to Each Finger
- Finger-Nose-Finger Test
- Heel-to-Shin Test
- Observe Gait
Skull, Scalp and Hair Assessment
- Inspect Size, Shape and Contour
- Inspect and Palpate Areas for Tenderness or Lesions
- Inspect for Tenderness, Lesions or Rashes
- Inspect for Dandruff
- Inspect for Lice or Nits
- Inspect Quality and General Appearance of Hair
- Observe Hair Distribution
Head, Face and Neck Assessment
- Inspect Size and Shape of Skull
- Palpate Temporal Artery
- Observe Facial Expression
- Inspect Facial Structures and Symmetry
- Look for Symmetry
- Check Range of Motion
- Inspect Lymph Nodes and Thyroid Gland
- Confirm Trachea is Midline
Eye Assessment
- Eye and Eyebrow Symmetry
- Eyeball Alignment
- Examine Cornea and Lens for Cloudiness
- Iris and Pupil Shape and Size
- Pupillary Light Reflex and Accommodation
- P.E.R.R.L.A
Nose Assessment
- Inspect for Deformity or Asymmetry
- Inspect for Inflammation and Skin Lesions
- Check for Nasal Obstruction
- Inspect Nasal Mucosa
- Note Discharge, Bleeding or Foreign Body
- Palpate the Sinus Areas
Ear Assessment
- Inspect Position and Symmetry
- Inspect for Lesions, Drainage, Nodules or Redness
- Inspect Opening of Ear Canal
- Insert Speculum
- Position Scope
- View Structures
- Light Reflect
- Whisper Test
- Weber’s Test
- Rinne Test
Throat and Mouth Assessment
- Inspect for Color, Asymmetry and Swelling
- Inspect Lips, Teeth, Gums and Oral Mucosa
- Assess Tongue
- Examine Pharynx with Tongue Depressor
Skin Assessment
- Observe for Abnormal Skin Pigmentation
- Inspect for Cyanosis
- Observe Skin for Pallor
- Observe for Jaundice
- Inspect for Erythema
- Check the Temperature
- Inspect for Diaphoresis or Dehydration
- Imprint Thumb Firmly for 3 to 4 Seconds
- Note the Characteristics
- Palpate Lesion
Nail Assessment
- View Index Finger at its Profile
- Look at Consistency
- Observe Color
- Check Capillary Refill
Gastrointestinal System Assessment
- Inspect Mouth, Jaw, Teeth, Gums and Oral Mucosa
- Inspect Tongue
- Palpate Areas for Tenderness/Lesions
- Inspect Abdominal Quadrants
- Auscultate
- Percuss
- Palpate
- Light Palpation
- Deep Palpation
- Check for Rebound Tenderness and Ascites
- Inspect Perianal Area
- Palpate Rectum with Gloved Index Finger
Abdomen Assessment
- 4 Quadrants
- Contour, Shape, Symmetry
- Umbilicus
- Bowel Stethoscope
- Vascular Sounds
- Percuss 4 Quadrants
- Tympany or Dullness
- Light Palpation
- Deep Palpation
- Rebound Tenderness
Reflexes Assessment
- Hyperactive
- Hypoactive
- Biceps
- Triceps
- Brachioradialis
- Patellar (Quadriceps)
- Achilles Tendon
- Plantar Reflex (Babinski Sign)
ROM Assessment
- Active ROM (AROM)
- Active Assisted ROM (AAROM)
- Passive ROM (PROM)
- Neck Flexion, Extension and Rotation
- Shoulder Flexion, Extension and Rotation
- Elbow Flexion and Extension
- Fingers and Wrist Flexion and Extension
- Hip and Knee Flexion
- Hip Abduction and Rotation
- Ankle Rotation
- Toe Flexion and Extension
- Lumbar Rotation and Spine Inspection
Cardiac and Circulation Assessment
- Inspect General Appearance
- Inspect Chest
- Note Location of Apical Impulse
- Percuss Chest Wall
- Auscultate Heart Sounds: S1, S2, S3, S4
- Auscultate for Pericardial Friction Rub and Murmurs
- Assess Skin, Fingernails and Toenails
- Check Carotid Artery and Jugular Vein
- Palpate Skin for Temperature, Texture, Turgor
- Check Capillary Refill Time
- Palpate Arterial Pulses Bilaterally
Male Urinary System Assessment
- Past Medical History
- Medications
- Urination Pattern
- Inspection
- Palpation
- Auscultation
- Percussion
- Intake and Output
- Characteristic of Urine
Male Reproductive System Assessment
- Inspect the Penis and Urethral Meatus
- Inspect the Scrotum, Testicles and Pubic Hair
- Inspect the Inguinal and Femur
- Palpate the Entire Penile Shaft
- Palpate Both Testicles
- Palpate Epididymides and Both Spermatic Cords
- Palpate for Direct or Indirect Inguinal Hernia and Femoral Hernia
- Palpate Prostate Gland
Female Reproductive System Assessment
- Past Genitourinary and Gynecological History
- Current and Past Medication Use
- Urine Collection and Characteristics
- Inspect External Genitalia
- Palpate External Genitalia
- Inspect Internal Genitalia Using Lubricated Speculum
- Examine Vaginal Wall for Color, Texture, and Integrity
- Examine Cervix for Color, Position, Size, Shape, Mucosal Integrity and Discharge
- Palpate Internal Genitalia
- Note Abnormal Findings
Airway and Lungs Assessment
- Examine Back of Chest
- Determine Respiratory Rate for 1 Minute
- Assess for Abnormalities with Uneven Movement or Use of Accessory Muscles
- Inspect Skin, Nails and Mucous Membrane
- Palpate for Crepitus, Tenderness, Alignment, Masses or Retraction
- Palpate for Tactile Fremitus
- Check Chest-Wall Symmetry and Expansion
- Note Resonance, Hyperresonance, Dullness and Tympany
- Use Diaphragm of Stethoscope to Listen to Full Inspiration and Full Expiration
- Ask Patient to Breathe Through Mouth
- Normal Breath Sounds
- Abnormal Breath Sounds
Strength Assessment
- Assess Patient Appearance for Abnormalities
- Observe ROM of Upper and Lower Extremities
- Hand Grips
- Dorsiflexion and Plantarflexion
- Hip and Knee Flexion Against Resistance
- Manual Muscle Test (MMT) Grading System