Comprehensive Assessment

John Smith is a patient currently in the hospital. He suffers from COPD and Congestive Heart Failure.

Inpatient Hospital Room

1. Perform a complete head-to-toe physical assessment, using proper sequence and technique from general survey through neurological, skin, cardiovascular, respiratory, GI, GU, and musculoskeletal systems.
2. Use inspection, palpation, percussion, and auscultation techniques appropriately across all body systems.
3. Identify normal and abnormal findings, including variations in vital signs, heart and lung sounds, skin integrity, and neurologic responses.
4. Demonstrate effective therapeutic communication to promote patient comfort, explain procedures, and elicit subjective data.
5. Prioritize patient privacy, comfort, and safety throughout the assessment process.
6. Accurately document both subjective and objective findings using approved formats such as SOAP or narrative notes.
7. Recognize when abnormal findings require escalation and use SBAR to report concerns to the instructor or provider.

1. Complete a thorough and systematic head-to-toe assessment independently within a reasonable timeframe.
2. Use correct techniques for each body system (e.g., auscultating lung and heart sounds, palpating pulses, assessing skin, testing reflexes).
3. Identify and describe abnormal findings such as crackles, edema, pressure injuries, or altered mental status.
4. Communicate clearly with the patient and maintain a respectful, professional demeanor throughout the assessment.
5. Demonstrate appropriate use of standard precautions, hygiene, and patient-centered draping.
6. Document the comprehensive assessment clearly and concisely using institution-approved terminology and formats.