HEALTH ASSESSMENT DOCUMENTATION
KEY POINTS
Date and Time
Write your name: first name is initial and full last name with SN/OCHS
Subjective and Objective data should have a minimum of 2 per findings
Format in documentation
Per system be followed
SKIN, HAIR AND NAILS
Subjective Data: Patient reported no history of skin disease, no rashes or bruising. On no
medications.
Objective Data:
Skin: Color tan-pink, warm to touch and with good skin turgor.
Hair: Even distribution, no presence of dandruff and head lice. Nails: No clubbing of fingers. Nail beds
pink with good capillary refill.
HEAD, FACE AND NECK
Subjective Data: Patient stated no history of head injury or neck pain. No limitations of motion,
lumps or swelling.
Objective Data:
Head: Normocephalic, no lumps and lesions
Face: Symmetrical, no drooping and involuntary movement.
Neck: Supple with full ROM and no pain. No lymph node enlargement. Trachea is midline, thyroid not
palpable.
EYES AND EARS
Subjective Data (Eyes): Patient reported vision is good, no blurring. No history of eye injury. Patient
doesn’t use glasses or contact lenses,
Subjective Data (Ears): Patient states hearing is good, no earaches and no history of ear infection or
hearing loss.
Objective Data (Eyes): Snellen chart is 20/20 in both eyes.
Fields normal by confrontation. Diagnostic position test show extra ocular movements re intact.
Sclera is white and clear. PERRLA.
Objective Data (Ears): Patient ears are equal in size bilaterally with no swelling, consistent color, no
lesions, tenderness and discharges. Responds appropriately to conversation.
NOSE, MOUTH AND THROAT
Subjective Data (Nose): Patient stated no history of sinus problem, epistaxis or allergy.
Subjective Data (Mouth and Throat): Patient states with occasional sore throat with colds, no
toothache and dysphagia. Visits dentist annually.
Objective Data:
Nose: Midline, no deformity or lesions. Nares patent. Absent of tenderness to sinuses during
palpation.
Mouth: Mucosa, gingivae and tongue is pink. Teeth are all present and in good repair.
Throat: Uvula is in midline. Tonsils are visible.
NOSE, MOUTH AND THROAT
Subjective Data (Nose): Patient stated no history of sinus problem, epistaxis or allergy.
Subjective Data (Mouth and Throat): Patient states with occasional sore throat with colds, no
toothache and dysphagia.
Visits dentist annually.
Objective Data:
Nose: Midline, no deformity or lesions. Nares patent. Absent of tenderness to sinuses during
palpation.
Mouth: Mucosa, gingivae and tongue is pink. Teeth are all present and in good repair.
Throat: Uvula is in midline. Tonsils are visible.
THORAX AND LUNGS
Subjective Data: Patient reported no history of respiratory diseases. Have experience once or twice
colds per year. Never had Chest X Ray.
Objective:
Inspection: Anteroposterior diameter is less than the transverse diameter. Respirations 16
breaths/minute, relaxed and even. Palpation: Chest expansion symmetric. Tactile fremitus equal
Bilaterally. No tenderness to palpation.
Percussion: Resonant to percussion over lung fields.
Auscultation: Vesicular breath sounds clear over lung fields. No adventitious sounds.
HEART & NECK VESSELS
Subjective Data: Patient reported no history of hypertension and any cardiovascular disease. On no
medications
Objective Data:
Neck: Carotids 2+ and equal bilaterally, Jugular vein pulsation presents.
Precordium: Inspection-no visible pulsation, Palpation-apical impulse in 5th left midclavicular line,
Auscultation-rate 68 beats per minute, rhythm regular and S1 and S2 are normal
PERIPHERAL VASCULAR SYSTEM
Subjective Data: Patient stated no history of heart or vascular problems. No skin changes on both
upper and lower extremities.
Objective Data:
Inspection: Extremities have pink-tan color without lesions. Size is symmetrical.
Palpation: Temperature is warm to touch; all pulses are present, grade 2+. No lymphadenopathy.
ABDOMEN
Subjective Data: Patient reported no history of abdominal disease, injury or surgery. Appetite is good
and has regular bowel movement.
Objective Data:
Inspection: Abdomen is flat and symmetric. Skin smooth with no lesions.
Auscultation: Bowel sounds present, no bruits.
Percussion: Tympanic in all quadrants. Liver span is 8cm and splenic dullness located at 10th
intercostals space in left mid
Axillary line.
Palpation: Soft, no masses and no tenderness.
MUSCULOSKELETAL SYSTEM
Subjective Data: Patient stated no history of bone trauma or deformity. Can do daily activities
without limitations
Objective Data:
Muscles: Symmetric and no swelling or masses. Muscle strength- able to maintain flexion against
resistance. Joints: Full ROM, no tenderness to palpation.
NEUROLOGIC SYSTEM
Subjective Data: No complaint unusual frequent headaches and head injury. No past history of
stroke, spinal cord injury, and meningitis
Objective Data:
Cranial Nerves: All cranial nerves are intact.
Reflexes: Normal reflexes, negative Babinski sign, DTR 2 + and bilaterally equal.
Motor and Sensory System: No atrophy, weakness or tremors, Gait is smooth and coordinated, able
to tandem walk, negative Romberg, Alternating movements, finger to nose smoothly intact
