What should be included in a general non-touch physical examination template?

General Non-Touch Physical Examination Template

A comprehensive non-touch physical examination should include vital signs measurement, general appearance assessment, and systematic observation of body systems without direct physical contact with the patient.

Vital Signs

• Temperature: Use non-contact infrared thermometer 1
• Blood pressure: Record systolic and diastolic readings 1
• Heart rate: Count for full minute or use pulse oximeter 2
• Respiratory rate: Count chest movements for full minute 2
• Oxygen saturation: Use pulse oximeter 2
• Height and weight: Record and calculate BMI 3

General Appearance

• Level of consciousness and alertness 1, 3
• Body habitus (evidence of wasting or obesity) 3
• Posture and gait (if patient is ambulatory) 1
• Skin color and visible abnormalities 1, 3
• Facial expression and affect 1
• Speech pattern and quality 1

Head and Neck Examination

• Facial symmetry and features 1
• Eye appearance (conjunctival color, scleral icterus) 1
• Pupillary response to light (can be assessed from a distance) 1
• Oral cavity inspection (if visible without contact) 3
• Neck inspection for visible masses or thyroid enlargement 3
• Jugular venous distension assessment 1

Chest and Respiratory Examination

• Respiratory pattern and effort 1
• Chest wall symmetry during respiration 1
• Use of accessory muscles 1
• Visible cough or respiratory distress 1

Cardiovascular Examination

• Visible precordial movements 1
• Extremity color and perfusion 1
• Visible edema in extremities 1
• Capillary refill time (can be assessed visually) 1

Abdominal Examination

• Abdominal contour and symmetry 1
• Visible distention or masses 1
• Visible peristalsis or pulsations 1

Neurological Examination

• Mental status assessment through conversation 1
• Cranial nerve assessment (facial symmetry, eye movements) 1
• Gross motor function observation 1
• Coordination assessment (if patient can perform tasks) 1
• Speech and language assessment 1

Musculoskeletal Examination

• Joint deformities or swelling 3
• Muscle bulk and symmetry 3
• Range of motion (observed while patient performs movements) 3
• Gait and balance assessment 1

Skin Examination

• Color, rashes, lesions visible on exposed skin 3
• Evidence of jaundice, pallor, cyanosis 1
• Presence of acanthosis nigricans 3
• Edema in visible areas 1

Documentation Format

• Document findings in a systematic head-to-toe approach 4
• Note any limitations of the non-touch examination 5
• Record quality of observations (clear view vs. limited assessment) 5
• Document time of assessment 4

Special Considerations

• For infectious disease precautions, maintain appropriate distance and use personal protective equipment according to risk level 1
• For primary protection: surgical mask or N95 mask 1
• For secondary protection (higher risk): add goggles, gown, and gloves 1
• For tertiary protection (highest risk): full PPE including head cover, face shield, double gowns and gloves 1

Common Pitfalls to Avoid

• Underestimating the importance of respiratory rate assessment (often overlooked but critical vital sign) 2, 6
• Failing to document a complete set of vital signs 4
• Not accounting for age-appropriate normal values 5
• Overlooking subtle signs of distress that can be observed without touch 2
• Inadequate lighting or positioning for proper visual assessment 6

This template provides a comprehensive framework for conducting a non-touch physical examination while still gathering essential clinical information to guide further assessment and management decisions.