Symmetric bilaterally
Asymmetric
Inspected Nose
Color (1/3 point)
1 of 1 poin
Discharge (1/3 point)
Pink
No discharge
Red
Clear discharge
Bluish
Bloody discharge
Purulent discharge
Observations (1/3 point)
No additional visible abnormal findings
Foreign body present
Polyp
Septum perforated
Septum deviated
Lesion
Inspected Back
1 of 1 poin
Appearance (1/1 point)
No visible abnormal findings
Rash
Moles or skin tags
Freckles, birthmark, or other discoloration
Excessive dry or flaking skin
Purpura
Striae
Scratching
Bruising
Inspected Eyes
Pupillary Reaction (1/3 point)
1 of 1 poin
Reaction (1/3 point)
Normal
Normal constriction and dilation
Unequal
Unequal or no pupillary constriction
Irregular
Unequal or no pupillary dilation
Miosis
Mydriasis
Non-reactive to light
Sclera (1/3 point)
White
Yellow Tint
Redness
Inspected Chest
Symmetry (1/2 point)
1 of 1 poin
Appearance (1/2 point)
Symmetric
No visible abnormal findings
Asymmetric
Redness
Rash
Moles or skin tags
Masses (warts, cysts, or tumors)
Freckles, birthmark, or other discoloration
Excessive dry or flaking skin
Purpura
Striae
Bruising
Scarring
Inspected Arms
Observations (1/3 point)
1 of 1 poin
Wounds Or Scars (1/3 point)
No visible evidence of self-harm or abuse
No visible wounds or scars
Evidence of self-harm
Wound visible
Scar visible
Location Of Visible Abnormality (1/3 point)
No visible abnormality
Right upper arm
Right lower arm
Right wrist
Right hand
Left upper arm
Left lower arm
Left wrist
Left hand
Auscultated Breath Sounds
Breath Sounds (1/2 point)
1 of 1 poin
Adventitious Sounds (1/2 point)
Clear in all areas
No adventitious sounds
Diminished in some areas
Wheezing
Absent in some areas
Fine crackles
Stridor
Rhonchi
Rales
Auscultated Heart Sounds
Heart Sounds (1/3 point)
1 of 1 poin
Extra Heart Sounds (1/3 point)
S1 and S2 audible
No extra sounds
S1, S2, and S3 audible
Gallops
S1, S2, and S4 audible
Murmur
S1, S2, S3, and S4 audible
Friction rub
Valve clicks
Rate And Rhythm (1/3 point)
Regular rate and rhythm
Irregular rate
Arrhythmia
Palpated Capillary Refill
Right Hand (1/2 point)
1 of 1 poin
Left Hand (1/2 point)
Less than 2 seconds
Less than 2 seconds
Greater than 2 seconds
Greater than 2 seconds
Palpated Radial Arteries
Right: Vibration (1/4 point)
1 of 1 poin
Right: Amplitude (1/4 point)
No Thrill
0 Absent
Thrill
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Left: Vibration (1/4 point)
Left: Amplitude (1/4 point)
No Thrill
0 Absent
Thrills
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Palpated Dorsalis Pedis Arteries
Right: Vibration (1/4 point)
1 of 1 poin
Right: Amplitude (1/4 point)
No Thrill
0 Absent
Thrills
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Left: Vibration (1/4 point)
Left: Amplitude (1/4 point)
No Thrill
0 Absent
Thrills
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Palpated Abdomen
Tenderness (1/5 point)
1 of 1 poin
Location Of Tenderness (1/5 point)
None Reported
No quadrants tender
Tenderness Reported
Right upper quadrant
Right lower quadrant
Left upper quadrant
Left lower quadrant
Observations (1/5 point)
Presence Of Unexpected Mass (1/5 point)
No additional observations
No palpable mass
Masses
Palpable mass
Guarding
Distension
Location Of Mass (1/5 point)
No palpable mass
Right upper quadrant
Right lower quadrant
Left upper quadrant
Left lower quadrant
Around umbilicus
Performed EKG
Sinus Rhythm (1/2 point)
1 of 1 poin
St Changes (1/2 point)
Regular
No ST elevation
Irregular
ST elevation present
Assessed Labs
Drug Screen Results (1/2 point)
1 of 1 poin
Thyroid Function Tests (1/2 point)
Positive for substances
Both levels within normal ranges
Negative for substances
Thyroxine-binding globulin elevated
Thyroxine-binding globulin low
Thyroid-stimulating hormone (TSH) elevated
Thyroid-stimulating hormone (TSH) low
Assessed General Appearance
Eye Contact (1/4 point)
0.75 of 1 po
Posture (1/4 point)
Direct eye contact
Upright posture without tension or rigidity
Indirect or no eye contact
Bent or hunched posture, tension, or rigidity
Clothing (1/4 point)
Clean clothing, appropriate to age, fit, season, and occasion
Dirty, disheveled, or inappropriate to age, fit, season, or
occasion
Grooming (No point)
Demonstrates an appropriate level of grooming
Signs indicating lack of grooming or self-care
Assessed Attitude Toward Medical Staff
1 of 1 poin
Attitude Toward Medical Staff (1/1 point)
Generally open and cooperative
Generally suspicious, guarded, or evasive
Assessed Speech
Rate (1/3 point)
1 of 1 poin
Volume (1/3 point)
Demonstrates appropriate or expected rate of speech
Demonstrates appropriate or expected speech volume
Excessively slow or rapid rate of speech
Excessively loud or soft speech volume
Articulation (1/3 point)
No appreciable issues with articulation
Issues with articulation, slurring, or stutters
Assessed Mood and Affect
Mood (1/2 point)
Stable mood with little or no fluctuation throughout the
interview
Frequent and appreciable mood changes throughout the
interview
1 of 1 poin
Affect (1/2 point)
Full or balanced (normal)
Expansive affect (excessively cheerful affect characterized b
contagious laughter or smiling)
Blunted or flat affect (little to no variation of expression
regardless of conversation topic)
Assessed Thought Process
1 of 1 poin
Thought Process (1/1 point)
No presence of thought process disturbances
Presence of rapid thinking, disorganized or illogical flow of
thought, "word salad," neologisms, echolalia, or clanging
associations
Assessed Thought Content
Thought Content (1/2 point)
No presence of thought content disturbances
Presence of delusions, obsessive or intrusive thoughts, or
suicidal or homicidal ideation
1 of 1 poin
Perceptual Disturbances (1/2 point)
No presence of perceptual disturbances
Presence of auditory or visual hallucinations
Confirmed Orientation
To Person (1/4 point)
1 of 1 poin
To Place (1/4 point)
Oriented to person
Oriented to place
Not oriented to person
Not oriented to place
To Time (1/4 point)
Oriented to time
To Situation (1/4 point)
Oriented to situation
Not oriented to time
Not oriented to situation
Assessed Serial Sevens
1 of 1 poin
Serial Sevens (1/1 point)
Able to complete the series
Unable to complete the series
Assessed Abstract Thinking
1 of 1 poin
Abstract Thinking (1/1 point)
Demonstrates abstract thinking with similarities test
Demonstrates concrete thinking with similarities test
Assessed Memory
1 of 1 poin
Memory (1/1 point)
Remote and immediate memory intact
Remote or immediate memory not intact
Assessed Visuospatial Ability
1 of 1 poin
Visuospatial Ability (1/1 point)
Visuospatial ability intact for interlocking shapes test
Visuospatial ability impaired with interlocking shapes test
Assessed Insight
1 of 1 poin
Insight (1/1 point)
Demonstrates full awareness of illness and willingness to seek
treatment
Demonstrates limited or no awareness of illness and/or is
unwilling to seek treatment
Assessed Judgment
1 of 1 poin
Judgment (1/1 point)
Demonstrates good judgment
Judgment poor or impaired judgment
Comments
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