Your checklists (
0
)
AI Checklist Generator
From the makers of
Manifestly Checklists
Sign in
Email address
Email me a magic link
Home
> Health assesment
Health assesment
I. Patient Identification
Verify patient’s name and date of birth
Confirm patient's identification with a government-issued ID
Assess patient's preferred language and communication needs
II. Medical History
Document past medical history
Record family medical history
Note any allergies and adverse reactions
Review current medications and supplements
Assess immunization status
III. Lifestyle and Social History
Evaluate smoking status and tobacco use
Assess alcohol consumption
Discuss recreational drug use
Review dietary habits and nutrition
Inquire about physical activity levels
Document living situation and social support systems
IV. Review of Systems
Conduct a comprehensive review of each body system (e.g., cardiovascular, respiratory, gastrointestinal, etc.)
Note any current symptoms or concerns reported by the patient
Document relevant findings from the physical examination
V. Vital Signs and Measurements
Measure and record blood pressure
Assess heart rate and rhythm
Document respiratory rate
Measure temperature
Record height and weight for BMI calculation
VI. Physical Examination
Conduct a head-to-toe physical examination
Assess skin condition and any lesions
Evaluate neurological function
Examine cardiovascular health (heart sounds, pulses)
Assess respiratory function (lung sounds, effort)
Check abdomen for tenderness or abnormalities
VII. Laboratory and Diagnostic Tests
Review any recent lab results (CBC, metabolic panel, etc.)
Document any imaging studies (X-rays, MRIs, etc.)
Order necessary tests based on findings
VIII. Assessment and Plan
Summarize findings from history and physical examination
Develop a differential diagnosis if applicable
Create a management plan including referrals, lifestyle modifications, and follow-up appointments
Educate the patient about their health status and next steps
IX. Documentation and Follow-Up
Ensure all findings and plans are documented in the patient's record
Schedule follow-up appointments as needed
Provide patient with a copy of their assessment and plan if appropriate
Download CSV
Download JSON
Download Markdown
Use in Manifestly
Use in Manifestly