Head to Toe Assessment

HEENT

[checkbox name="HEENT" value="FACE SYMMETRICAL WITH NO FACIAL DROOP|WHITE SCLERA, CONJUNCTIVA PINK/RED WITHOUT VISION CHANGES, PUPILS EQUAL AND REACTIVE TO LIGHT|DENIES:EAR PAIN,DRAINAGE FROM EARS, NASAL CONGESTION, SORE THROAT, COUGH, AND NECK PAIN|TRACHEA MIDLINE WITHOUT DEVIATION|ATRAUMATIC|TRAUMA-ACTIVE BLEEDING FROM ____|TRAUMA-NO LONGER BLEEDING FROM ____|JAUNDICE|LEFT EYE BLIND|RIGHT EYE BLIND|PUPILS DILATED|PUPILS PINPOINT|"]

CHEST

[checkbox name="CHEST" value="BILATERAL CHEST RISE AND FALL, NO SIGNS OF TRAUMA, BREATH SOUNDS IN ALL 4 QUADRANTS.|FLAIL CHEST|ABSENT BREATH SOUND IN THE ____|DIMINISHED BREATH SOUND ____|SEAT BELT BRUISING|PENETRATING TRAUMA|BLUNT FORCE TRAUMA"]

ABDOMEN

[checkbox name="ABDOMEN" value="SOFT NON-TENDER X4 QUADRANTS, DENIES PAIN X 4 QUADRANTS, NO TRAUMATIC INJURIES, NO ABD HERNIAS, NO REBOUND TENDERNESS WITH PALPATION|FEEDING TUBE|COLOSTOMY|TRAUMATIC INJURY|PAIN IN UPPER RIGHT QUADRANT|PAIN THE THE LOWER RIGHT QUADRANT|PAIN IN THE UPPER LEFT QUADRANT|PAIN IN THE LOWER LEFT QUADRANT"]

BACK

[checkbox name="BACK" value="DENIES BACK PAIN, SPINE MID-LINE, NO STEP OFF UPON PALPATION, NO SIGNS OF TRAUMA|UPPER BACK PAIN|LOWER BACK PAIN|LEFT SIDED FLANK PAIN|RIGHT SIDED FLANK PAIN|HISTORY OF SPINAL SURGERY|PRESSURE ULCER STAGE ____"]

UPPER EXTREMITIES

[checkbox name="UPPER EXTREMITIES" value="BILATERAL RADIAL PULSES PRESENT, SKIN TURGER <3 SECONDS, CAP REFILL <3 SECONDS|POOR SKIN TURGER|CAP REFILL >3 SECONDS|LEFT ARM AMPUTATED BELOW ELBOW|LEFT ARM AMPUTATED ABOVE ELBOW|RIGHT ARM AMPUTATED BELOW ELBOW|RIGHT ARM AMPUTATED ABOVE ELBOW"]

LOWER EXTREMITIES

[checkbox name="LOWER EXTREMITIES" value="BI-LATERAL PEDAL PULSES PRESENT, NO EDEMA NOTED, NO WOUNDS, |LEFT BKA|LEFT AKA|RIGHT BKA|RIGHT AKA|PITTING EDEMA|POOR CIRCULATION|DIABETIC ULCERS|PRESSURE ULCERS "]