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Physical Exam STUDY NAME Site Number: Pt ID: Visit Type (circle one): Screening Baseline Visit 1 NORMAL OR ABNORMAL Normal Abnormal Not Examined Normal Visit Date: / / 2 0 d d m m m y y y y Visit.

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It includes a routine check of vitals like blood pressure, heart rate, respiration, and temperature. Your doctor may also examine your abdomen, extremities, and skin for any signs of health changes.

PHYSICAL EXAMINATION - Normal. Vital signs: BP 120/80; P 68/min reg; RR 14/min; T 36.9 °C; Wt. ... General: Well-developed, well-nourished, appearing stated age. ... Head: Normocephalic without scalp lesions. ... Neck: Neck supple with full range of motion (ROM). ... Chest & back: No abnormal curvature of spine. ... Lungs: ... Cardiovascular:

Objective means that it is measurable and observable. In this section, you will report anything you and the client did; scores for screenings, evaluations, and assessments; and anything you observed. The O section is for facts and data. The O section is NOT the place for opinions, connections, interpretations, etc.

Examples of objective assessment include observing a client's gait , physically feeling a lump on client's leg, listening to a client's heart, tapping on the body to elicit sounds, as well as collecting or reviewing laboratory and diagnostic tests such as blood tests, urine tests, X-ray etc.

In general, the standard physical exam typically includes: Vital signs: blood pressure, breathing rate, pulse rate, temperature, height, and weight. Vision acuity: testing the sharpness or clarity of vision from a distance. Head, eyes, ears, nose and throat exam: inspection, palpation, and testing, as appropriate.

This part of the SOAP framework focuses on the objective data from the patient encounter. This can include observations of client behaviors, the treatment methods you've used, client responses to those methods, any measurable outcomes throughout the course of treatment.

Physical examination is the process of evaluating objective anatomic findings through the use of observation, palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient's history and pathophysiology.

Patient history (including symptoms) is recorded in the subjective section. Physical findings and results of diagnostic testing (e.g., imaging, laboratory, electromyographic, etc) are recorded in the objective section.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232