Objective Information
Measurements: (e.g., Write your patient’s Height (in cm), Weight (in kg), Waist circumference (in inches), BMI, and all vital signs)
General Survey: (e.g., You may say that your patient (add name here) is a 23-year-old female who appears stated age who articulates clearly, ambulates without difficulty, and is in no distress)
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Skin:
Head:
Eyes:
Ears:
Nose:
Mouth:
Throat/Neck:
Spine/back:
Thorax/Lungs:
Breast:
Heart:
Abdomen:
Genitourinary:
Extremities:
Musculoskeletal:
Neurological:
Actual and/or Potential Risk Factors
1. Patient is at risk for ………………………………………………. because the assessment findings indicate……………………….
2. Patient is at risk for………………………………………………. because the assessment findings indicate that…………………………………
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