Health Assessment Skills Check-Off Exam
Health Assessment Skills Check-Off Exam
Directions: This form will be used to evaluate your performance during the final physical exam assessment. Present this form to the adjunct faculty/instructor prior to the start of your exam.
Tips for successful preparation:
• Watch the GCU Head-to-Toe video two or three times per week. This video is used for the advanced practice nursing students; however, it demonstrates appropriate technique for all of the skills on this check-off.
• Practice the assessment skills 30-60 minutes daily.
• Incorporate YouTube videos on all assessment skills and techniques.
• Ask questions.
• Familiarize yourself with all areas on the form; remaining systematic and organized.
• Develop a flow and time yourself.
• Practice until you are comfortable.
• Refer to the rubric in the classroom on the required details to each area of this check-off.
• You will be given 60 minutes to complete this check-off.
There are 250 possible points. You are required to achieve a 76% (190 points) as the minimum score on this exam. You will have two attempts to successfully pass this check-off. If you do not achieve 76% on the initial Skills Check-Off Exam, you will be required to remediate and repeat the needed areas of improvement.
Points will be earned based on successful completion of each item/task, as well as display of technical skill (where applicable).
Name:
E-mail: Date:
Evaluator (Adjunct faculty/instructor)
Instructor: Performance:
Pass ______ Grade: ______
No Pass _____
Remediation Required
Completed Remediation:
Yes_________ No__________ NA ________
Performance:
Initial: _____ Retest: ______ NA ________
Final Physical Exam Assessment
Directions: This form will be used by the faculty to evaluate your performance during the final physical exam assessment. Present this form to the faculty prior to the start of your exam. Points will be earned based on successful completion of each item/task, as well as display of technical skill (where applicable).
Initial Approach and History Taking Points Possible Points Earned
Introduce self, identify role, explain intent for exam, gather supplies, wash hands. 2
Obtain patient identification information – Age, gender, race, date of birth. 2
Complete an HPI workup using OPQRST. 6
Total for Initial Approach and History Taking (Out of 10)
Past Medical History Points Possible Points Earned
General Health – Include last dates/findings of exams 2
Chronic Illness – What, when, how treated 2
Infectious Diseases 2
Allergies 2
Surgery – Type, complications, anesthesia 2
Injuries 2
Previous Hospitalizations 2
Immunizations 2
Female – GYN 2
Male and Female 2
Total for Past Medical History (Out of 20)
Family History Points Possible Points Earned
Grandparents, parents, siblings, children – Health status, age, cause of death 2
CVD 2
Neurological 2
Pulmonary 2
Endocrine 2
Osteoporosis 2
Obesity 2
Cancer 2
Bleeding Disorders 2
Mental/Emotional 2
Seizures 2
Substance Abuse 2
Total for Family History (Out of 24)
Social History Points Possible Points Earned
Place of Birth 2
Nationality/Ethnicity 2
Marital Status 2
Occupation 2
Military History 2
Social and Economic Status 2
Habits 2
Tobacco/Alcohol/Drug Use 2
Emotional, Sleep 2
Violence and Safety 2
Children 2
Total for Social History (Out of 22)
Review of Systems Points Possible Points Earned
Constitutional 2
Eyes 3
ENT/Mouth 3
Cardiovascular 3
Respiratory 3
GI 3
GU 3
M/S 3
Skin/Breasts 3
Neurologic 3
Psychiatric 3
Endocrine 3
Hem/Lymph 3
Allergic/Immunologic 3
Total for Review of Systems (Out of 41)
Initial Physical Exam Points Possible Points Earned
General Appearance 2
Assess Vital Signs 2
Total for Initial Physical Exam (Out of 4)
Exam of Head and Neck Points Possible Points Earned
Inspect and Palpate head
Describe normal findings
Cranium palpate shape, appearance, hair/scalp appearance 3
Name all cranial nerves and demonstrate appropriate assessment testing for all Cranial nerves I-XII 12
Neck – Demonstrate thyroid exam
Palpate and name all lymph nodes of the neck. 7
Opthalmascopic Exam 5
Ears 5
Nose 5
Mouth/Throat 6
Total for Exam of Head and Neck (Out of 43)
Exam of Posterior Thorax Points Possible Points Earned
Inspect Skin 2
Inspect Thorax and AP Diameter 5
Palpate Spine 2
CVA Assessment 2
Auscultate Lung Fields 2
Total for Exam of Posterior Thorax (Out of 13)
Exam of Anterior Thorax Points Possible Points Earned
Inspect Skin 2
Skin Turgor 2
Palpate Ribs and Sternum 2
Auscultate Lung Sounds 2
Auscultate heart first sitting then lying down 7
Teach BSE 2
Total for Exam of Anterior Thorax (Out of 17)
Exam of Abdomen Points Possible Points Earned
Inspect Abdomen 2
Auscultate BS 4 quadrants + assess for bruits in pertinent locations 8
Percuss abdomen including liver and spleen 2
Palpate light and deep 4 quadrants, liver, spleen, kidneys 7
Assess pulses and lymph nodes 2
Teach Male TSE 2
Total for Exam of Abdomen (Out of 23)
Exam of Upper Extremities Points Possible Points Earned
Inspect Skin 2
ROM and Muscle Strength 3
Palpate and name lymph nodes 2
Name and demonstrate assessment of DTRs 3
Sensory Assessment 2
Assess and name location of pulses, capillary refill 3
Total for Exam of Upper Extremities (Out of 15)
Exam of Lower Extremities Points Possible Points Earned
Inspect skin 2
ROM and Muscle Strength 5
Scoliosis Check 2
Name and Demonstrate assessment of DTRs 2
Sensory Assessment 2
Assess gait, coordination and balance – which tests 2
Assess and name location of pulses 3
Total for Exam of Lower Extremities (Out of 18)
The overall summary of your performance on the Final Physical Exam Assessment is presented below. Section totals are transferred to the table below from the information recorded above.
SECTION PERFORMANCE SECTION TOTAL
Initial Approach and History Taking
Past Medical History
Family History
Social History
Review of Systems
Initial Physical Exam
Exam of Head and Neck
Exam of Posterior Thorax
Exam of Anterior Thorax
Exam of Abdomen
Exam of Upper Extremities
Exam of Lower Extremities
SUMMARY OF OVERALL PERFORMANCE:
Student Signature: ______________________________________ Date ______________
Evaluator Signature: ____________________________________ Date ______________
Remediation Plan:
_______ Evaluator reviewed and demonstrated areas of needed improvement.
_______ I will review my notes from the readings and class.
_______ I will spend ____ hours preparing and practicing for the repeat exam
in 7-10 days.
_______ I will schedule my repeat assessment check off in 7-10 days.
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Student Signature: _______________________________________ Date ______________
Evaluator Signature: _____________________________________ Date ______________
Review Details
Take a moment to review the details of this assignment below and gather any necessary files. Once you're ready to submit your assignment, move on to Step 2.
Assessment Description
Read the "NUR-643E Procedures for Advanced Health Assessment Check-Offs" and submit your response below in this forum within the allotted timeframe for completion:
Procedures for Advanced Health Assessment Check-Offs Acknowledgement:
I, (INSERT NAME), verify that I have read, understand, and will comply with the requirements set forth in the "NUR-643E Procedures for Advanced Health Assessment Check-Offs" document.
Health Assessment Skills Check-Off Exam
Name of the Student
Department; Institution of Affiliation
Course Code: Course Title
Due Date
Introduction
Nursing health evaluation is a powerful tool in the nurse's toolbox. Patients' symptoms, development, and accompanying physical findings may all be obtained via an in-depth examination by a professional nurse. This enables the creation of possible diagnoses based on this information. Both subjective and objective data are used in the assessment process. The patient's perceptions of the evaluation process are called "subjective assessment factors." What can be seen and quantifiable constitutes objective assessment data (Jarvis, 2012). A thorough medical history might help discover possible or underlying health conditions. The next phase is to execute the strategies and interventions that will make up the health program when the evaluation and planning stages have been completed. We need to know how the patient's symptoms started and how they progressed to make an accurate diagnosis (Bickley et al., 2017). A thorough health history is essential in healthcare settings to offer high-quality patient-centered care, minimize medical mistakes, maintain patient safety, and reduce mortality and morbidity by detecting illnesses early. Patients' requirements, medical management priorities, and potential medical crises may all be discovered via health interviews. Patients' present health, behavior, and risk status are shown.
Physical Exam Documentation
Chief Complaint: The patient claims he's been here for a week with lower back discomfort. Before this, there had been no additional incidents of back discomfort. He was experiencing a 5-day discomfort increase. Relieved by resting, walking increased the pain, and ascending stairs worsened, but no previous history of trauma or injury. The lower back discomfort had impacted her everyday life.
History of Present Illness: Mr. Bob, a 65-year-old Asian American, described intense intermittent lower back pain, tingling, and numbness in both lower limbs. As if that wasn't enough, my legs are usually cold. The patient had complained of low back pain two weeks before after moving a bulky object at home. The pain is achy and intermittent, and it is located in the Centre of her lower back. It gives him a tingling sensation down his legs at times. In addition to rolling over in bed and sitting for an extended amount of time, these activities aggravate the pain. To receive some relief, I've taken over control of my pain medications. Rest and a change in posture may also help relieve pain.
Past Medical History (HX): According to Mr. Bob, he had been in excellent health until the fall. He says he takes medicine to lower his blood pressure. He has no long-term health issues. That he hasn't been exposed to infectious illnesses such as TB or HIV is a claim he denies making. Mr. Bob claims that he got all of his childhood vaccinations and received the flu vaccine in October 2019. He also mentioned that he does his monthly self-testicular examinations and that he had no discomfort or pain.
Hospitalization: Mr. Bob says he has never been to the hospital.
Past Surgical History: While Mr. Bob was three years old, he underwent a tonsillectomy, and when he was in college, an appendectomy.
Family History: Mr. Bob's parents, who are in good health, are alive and well. Hypertension has been a concern for his 80-year-old father in the past, but he takes his medicine and has no additional issues. Although his mother, 75, has hypertension and diabetes, she follows her doctor's orders, takes her medicine, and engages in some light exercise. His older siblings, both in their 40s, are fit and healthy. Mr. Bob's grandparents have passed away as a result of their advanced years. There have been no reports of any health issues with Bob's two children. None of the family members suffers from a heart attack, Parkinson's, or any other significant ailment that needs hospitalization. He also denies that any of the family members suffer from bronchitis or pneumonia. He also said that no one in his family suffers from obesity or allergies. He says he has no family history of cancer, and he has no mental health issues like anxiety, despair, PTSD, or any thoughts of self-harm or homicide. He says he has no autoimmune diseases like lupus or bleeding problems like thrombocytopenia. He also says he has no genetic illnesses like down syndrome. No one, he claims, suffers from seizures. There would be no alcohol or illegal substances in Bob's household, he said.
Social History
Smoking History: A local hospital-employed Mr. Bob at the age of 22. He completed his undergraduate studies at a community college, and there were no language obstacles to contend with. He and his wife and two children, ages 15 and 17, reside in their own home. His wife has a part-time job as a secretary at the local hospital, which she enjoys. They have enough money to pay their financial obligations. He is neither a drinker nor does he engage in any illegal substance usage. For an hour each week, he works out at the gym four times a week. Due to discomfort, he's been unable to sleep for the last two weeks, but he claims that he has no safety worries in the house.
Allergies: It seems that Mr. Bob has no sensitivities to medication, food, or even seasonal chemicals.
Medications: These are the medications he's now taking at home.
Tab Lisinopril 10mgs twice a day,
Tab Simvastatin 20mgs at night,
Tab. Metoprolol 50mgs daily,
Tab Aspirin 81mgs daily,
Tab Tylenol 500mgs PRN as needed for pain
Review of symptoms by system
As an account of the patient's bodily systems, a review of systems (ROS) is collected via a sequence of questions that aim to identify indications and symptoms.
General Health: Mr. Bob claims that he was in good health until he started experiencing lower back discomfort. He is in perfect health.
Head, Eyes, Ear, Nose, and Throat (HEENT): There has been no change in Bob's eyesight or discharges from his eyes, according to Mr. Bob. He denies that he has any hearing or ear infection or discharge. He claims to have no nasal congestion, bleeding, or soreness. He says nothing is wrong with his mouth and denies having any odd tumors on his lips.
Cardiovascular System: Mr. Bob denies having ever had cardiac problems, an irregular heart rate, or any other abnormal heart rhythms, and he also denies having any chest pains.
Respiratory System: Mr. Bob claims that he has never had asthma, pneumonia, sleep apnea, pulmonary embolism, or TB in...