The objective of the Documentation of Normal Findings Assignment is to demonstrate understanding of a comprehensive ROS and physical examination of the focus system. It is essential to understand and recognize what is normal in order to identify abnormal findings. Use the template as a guide.

Normal findings change over time. Assume each patient has presented to the clinic for a comprehensive wellness exam. Subjective and objective findings are NORMAL. Demonstrate that you know specific questions to ask to obtain a detailed subjective history for the focus system for a selected (pediatric, adult, OR geriatric) patient, and objective findings for a focused physical examination, including specialty maneuvers for a pediatric, adult, AND geriatric patient. Complete the following for each focus system.

• Identify the focus system.
• Subjective Findings – Identify the population (pediatric, adult, OR geriatric patient)
• Enter data for a comprehensive ROS (Subjective History) for the focus system for the identified patient population. All reported information should be NORMAL.
• Objective Findings – Determine the age of EACH patient within each category (pediatric, adult, and geriatric). For example, consider that the skin assessment of a newborn versus a teenager is very different.
• Enter data for a comprehensive physical examination of the focus system for EACH patient. All data should represent NORMAL findings.
•  

Note that objectives findings are needed for a pediatric, adult, and geriatric patient.

NU650 DOCUMENTATION OF NORMAL FINDINGS TEMPLATE

Normal findings change over time. Assume each patient has presented to the clinic for a comprehensive wellness exam. Subjective and objective findings are NORMAL.  Demonstrate that you know specific questions to ask to obtain a detailed subjective history for the focus system for a selected (pediatric, adult, OR geriatric) patient, and objective findings for a focused physical examination, including specialty maneuvers for a pediatric, adult, AND geriatric patient. Complete this template for EACH focus system.

Focus System (Select one): __ Skin    __HEENT   __ Thorax/Lungs   __ Musculoskeletal   __ Neurological

Subjective History (select only one): ___ pediatric   ___ adult     ___ geriatric patient:

Objective Findings for Patients Across the Lifespan:

Pediatric Patient

Adult Patient

Geriatric Patient

Age of Patient ______

Objective exam findings:

Age of Patient _____

Objective exam findings:

Age of Patient _____

Objective exam findings:

Focus System (Select one): __ Abdomen   __ Neck   __ Cardiac/PV    __ Male/Female GU (include both female and male findings)

Subjective History (select only one): ___ pediatric   ___ adult     ___ geriatric patient:

Objective findings for patients across the lifespan:

Pediatric Patient

Adult Patient

Geriatric Patient

Age of Patient ______

Objective exam findings:

Age of Patient _____

Objective exam findings:

Age of Patient _____

Objective exam findings:

PLease see attachments for details.