Assessment Skills Checklist

Patient Information

Patient Name

Date & Time of Assessment

Age / Gender

Primary Diagnosis

Assessment Preparation

Instructions: Before beginning assessment, complete these preparation steps.

Preparation Checklist

Perform hand hygiene

Explain procedure to patient in understandable terms

Ensure privacy - close curtain/door

Position patient appropriately for assessment

Gather equipment (stethoscope, penlight, thermometer, watch)

Ensure adequate lighting

Warm hands and stethoscope before touching patient

Vital Signs Assessment

Vital Sign	Finding	Normal Range	Abnormal?
Temperature		36.5-37.5°C
Pulse		60-100 bpm
Respirations		12-20 breaths/min
Blood Pressure		<120/80 mmHg
Pain Level		0-10 scale

General Survey

Instructions: Observe the patient's overall appearance, behavior, and level of distress from the moment you enter the room.

General Appearance & Hygiene

Level of Consciousness & Mental Status

Mood & Affect

Level of Distress

Skin Color & Condition

Mobility & Positioning

Head & Neck Assessment

Head & Neck Checklist

Scalp & Hair - inspect for lesions, distribution, cleanliness

Eyes - assess visual acuity, pupils (PERRLA), eye movement

Ears - inspect external ear, check cerumen, assess hearing

Nose - assess patent airway, mucous membranes, septum

Mouth & Throat - inspect teeth, tongue, gums, throat, oral hygiene

Sinuses - palpate for tenderness

Neck ROM - check for stiffness, limitation

Lymph Nodes - palpate for enlargement, tenderness

Thyroid Gland - palpate for size, nodules, tenderness

Head & Neck Findings / Abnormalities

Chest & Lungs Assessment

Chest & Lungs Checklist

Chest Shape - symmetrical, barrel chest, deformities

Respiratory Movement - palpate for equal expansion

Percussion - all lung fields (resonant vs dull sounds)

Auscultation - all lung fields for breath sounds

Breath Sounds - clear, absent, diminished, adventitious sounds

Respiration Pattern - rate, depth, rhythm, use of accessory muscles

Chest & Lung Findings / Abnormalities

Cardiovascular Assessment

Cardiovascular Checklist

Heart Sounds - listen for S1, S2, murmurs, extra sounds

Apical Pulse - rate, rhythm, quality

Radial & Pedal Pulses - palpate bilaterally for rate, rhythm, strength

Edema - check extremities for pitting or non-pitting edema

Capillary Refill - press nail bed, should return in <2 sec

Jugular Venous Pressure - assess neck veins for distention

Skin Temperature - warm, cold, clammy

Cardiovascular Findings / Abnormalities

Abdomen Assessment

Important: Assess in this order: Inspection → Auscultation → Percussion → Palpation (palpation last to avoid increasing bowel sounds)

Abdomen Checklist

Inspection - shape, symmetry, distention, scars, lesions

Auscultation - bowel sounds all quadrants (present, hyperactive, hypoactive, absent)

Auscultation - vascular sounds (bruits over aorta, renal artery)

Percussion - all quadrants (resonance vs dullness)

Palpation Light - all quadrants, check for tenderness, guarding

Palpation Deep - all quadrants, feel for masses, organomegaly

CVA Tenderness - percuss over kidneys for tenderness

Abdomen Findings / Abnormalities

Extremities Assessment

Extremities Checklist

Muscle Strength - test both sides, grade 0-5

Range of Motion - assess all major joints (shoulder, elbow, wrist, hip, knee, ankle)

Sensation - test light touch, temperature, pain in extremities

Nails & Extremities - check for clubbing, cyanosis, color changes

Joints - assess for swelling, warmth, redness, range of motion

Extremities Findings / Abnormalities

Neurological Assessment

Neuro Assessment Checklist

Orientation - person, place, time, purpose

Pupils - size, shape, equality, light reaction (PERRLA)

Movement - strength, coordination, tremor

Reflexes - assess (if trained): patellar, achilles, biceps, triceps

Speech - clear, slurred, difficulty finding words, appropriate

Mood & Affect - congruent, appropriate to situation

Neurological Findings / Abnormalities

Assessment Pearls & Tips

Key Assessment Practices

Warm hands and stethoscope before touching patient

Use sequence consistently - develop a routine that becomes automatic

Observe before palpating - don't mask visual findings

Compare bilateral findings - use patient as own control

Note deviations from normal and report abnormalities promptly

Practice on healthy volunteers to develop baseline normal findings

Don't skip areas even if patient appears stable - something might change

Allow extra time initially - speed develops with practice

Overall Assessment Summary

Abnormal Findings Summary

Assessment Completed By

Documentation

Student Signature / Date

Instructor Signature / Date (Optional)

PHYSICAL ASSESSMENT SKILLS CHECKLIST