Certification exam assisting with Physical examinations
Assessment of body systems (review of symptoms)
Personal history
Family medical history
Past medical history
Chief complaint
Objective findings
Database
Problem list
Initial plan
Progress notes
Hypertension
Diabetes
Pregnancy
Arthritis
Dizziness
Subjective
Objective
Assessment
Plan
Problem list
Double-checking to make sure that you have the correct patient chart
Using black ink
Lengthy, superfluous entries
The patient's name should appear on each page of the record
Dating and initialing each entry
Have the patient undres from the waist up
Take the patient's height, weight, vital signs
Have the patient empty his or her bladder
The medical assistant remaining in the room with an elderly patient
The removal of all clothing, including unbderwear and stockings
Sims'
Spne
Fowler's
Trendelenburg
Knee-chest
Proctologic
Knee-chest
Lithotomy
Prone
Semi-Fowler's
Mesuration
Inspection
Palpation
Percussion
Ausculation
Opthalmoscope
Percussion hammer
Otoscope
Sthethoscope
Tuning fork
Sphygomomanometer
Syringe
Fixative
Penlight
Nasal speculum
Blood chemistry profile & complete blood count
Electrocardiogram
Visual acuity
Pulmonary function test
All of the above
Tuning fork
Emesis basin
Percussion hammer
Laryngeal mirror
Proctosigmoidoscope
Mother deceased
Sleeps 8 hours a night on average
Vomiting
Tonsillectomy
Respirations regular
Cc: " I have pain on the right side of my stomach"
Cc: "The patient c/o pain in the RLQ of the abdomen
B/P: 120:70 R:16 T:99.6
Allergies: none, Meds: none
The pts. Troat appears to be infected with strep
Hematuria
Leukoplakia
Hemoptysis
Laryngitis
Tinnitus
Hernia
Axilla
Renal colic
Inguinal
Orifice
Urticaria
Leukorrhea
Cyanosis
Rosacea
Oliguria
Otoscope
Opthalmoscope
Tonometer
Penlight
Titmus II
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