What should be included in a comprehensive physical assessment template?

Comprehensive Physical Assessment Template

A comprehensive physical assessment template should include vital signs, general appearance, head-to-toe examination, and specialized assessments based on patient population, with documentation of all findings in a systematic manner. 1

Initial Preparation and Vital Signs

• Measure and document vital signs including temperature, pulse rate, respiratory rate, blood pressure (in both arms), and oxygen saturation 2, 1
• Calculate body mass index (BMI) by measuring height and weight 2, 1
• Assess orthostatic blood pressure changes when indicated (measure blood pressure lying, sitting, and standing) 2, 1
• Note: Vital sign accuracy is critical - automated devices generally provide more reliable measurements than manual techniques for heart rate and respiratory rate 3

General Assessment

• Evaluate overall appearance, level of consciousness, and apparent distress 2, 1
• Assess body habitus for evidence of wasting, obesity, or lipodystrophy 2, 1
• Document growth variables in pediatric patients (length, weight, occipitofrontal circumference) 2

Head and Neck Assessment

• Inspect head for deformities, lesions, symmetry, and fontanelles (in infants) 2, 1
• Examine eyes, including visual acuity, pupillary response, extraocular movements, and fundoscopic examination 2, 1
• Assess ears including tympanic membranes 2
• Evaluate nose and mouth for congestion, lesions, ulcers, and evidence of trauma 2
• Palpate thyroid gland and lymph nodes in the neck 2, 1

Cardiovascular Assessment

• Auscultate heart for rate, rhythm, and abnormal sounds 2
• Palpate peripheral pulses, including femoral, popliteal, dorsalis pedis, and posterior tibial 2, 1
• Assess for capillary refill time, rubor on dependency, pallor on elevation, and venous filling time 2, 1
• Evaluate for peripheral edema 2

Respiratory Assessment

• Observe respiratory effort and pattern 2
• Auscultate lungs for normal breath sounds and adventitious sounds 2
• Palpate chest for tenderness, crepitus, or irregularities 2

Abdominal Assessment

• Inspect abdomen for distention, visible masses, or abnormal movements 2
• Auscultate bowel sounds 2
• Palpate for organomegaly, masses, and tenderness 2
• Assess for hepatomegaly or splenomegaly 2, 1

Musculoskeletal and Neurological Assessment

• Evaluate muscle tone, strength, and symmetry of movement 2
• Assess gait and balance when appropriate 2
• Evaluate mental status and cognitive function 2, 1
• Test sensory function using the 10-g monofilament test, pinprick or temperature perception, and vibration testing with a 128-Hz tuning fork 2, 1
• Assess deep tendon reflexes 2

Skin Assessment

• Perform comprehensive skin examination, noting any lesions, ulcerations, calluses, or wounds 2, 1
• Document color, perfusion, and evidence of injury 2
• Pay particular attention to feet and pressure points in patients at risk for skin breakdown 2, 1

Genitourinary Assessment

• Examine external genitalia for abnormalities, lesions, or discharge 2
• Include pelvic examination for female patients when indicated 2

Special Considerations for Specific Populations

• For diabetic patients, perform comprehensive foot examination at least annually 2
• For psychiatric patients, include depression, anxiety, and substance use screening 2
• For older adults, apply the "Geriatric 5Ms" framework: Mind, Mobility, Medications, what Matters most, and Multicomplexity 1
• For pediatric patients, include assessment of developmental milestones 2
• For patients with eating disorders, document patterns of restrictive eating, food avoidance, binge eating, and compensatory behaviors 2

Laboratory and Diagnostic Evaluation

• Initial laboratory evaluation should include complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, fasting blood glucose or glycohemoglobin, lipid profile, liver function tests, and thyroid-stimulating hormone when indicated 2, 1
• Consider 12-lead electrocardiogram and chest radiograph when indicated 2, 1

Documentation and Follow-up Planning

• Document all findings systematically 1
• Develop a treatment plan based on assessment findings 2
• Provide patient education on self-examination techniques when appropriate 2, 1
• Schedule appropriate follow-up based on assessment findings 2