medical bedside physical examionation form
I. Patient Identification
- Greet the patient warmly.
- Ask for their full name.
- Request the date of birth clearly.
- Match provided information with the medical records.
- Ensure there are no discrepancies.
- Locate the patient's medical record number in the file.
- Ask the patient to provide their medical record number.
- Cross-check the number with the system database.
- Confirm the number matches the patient’s identity.
- Document any issues found.
- Inquire about any known allergies from the patient.
- Ask about previous allergic reactions to medications.
- Document the patient's allergy status in the records.
- Verify if there are alerts in the system.
- Ensure proper communication of any allergies.
II. General Assessment
- Check for body posture and movement.
- Look for signs of malnutrition or dehydration.
- Assess skin color, temperature, and any abnormalities.
- Note any visible physical injuries or conditions.
- Determine if the patient is alert and oriented.
- Ask simple questions to gauge responsiveness.
- Use the AVPU scale: Alert, Verbal, Pain, Unresponsive.
- Observe eye contact and reaction to stimuli.
- Look for facial expressions indicating pain.
- Listen for labored breathing or abnormal sounds.
- Observe body language, such as fidgeting or guarding.
- Assess the patient's ability to communicate discomfort.
- Check for cleanliness of skin and hair.
- Assess the condition of clothing and shoes.
- Look for signs of self-care neglect.
- Note any unusual body odors.
Use in Manifestly