Objective assessment Objective notes

  • cough
    HIV
  • dizzinessnocturnal pain/ drop attacks/
  • coughspeaking/ swallowing problem

  • dizziness
    dizziness
  • coughcancer/ inflammatory arthritis
  • dizziness
    TB
  • cough
    weight loss/ fevers
  • dizziness
    less than 20/ more than 55
  • cough
    double vision
  • cough
    severe pain
  • cough
    spinal cord compression
  • cough
    significant vertebral tenderness
  • cough
    neck trauma/ surgery
  • cough
    preceding trauma or neck surgery

Please seek medical help if any of the above apply or else confirm that you have checked that none do.

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      Health check Before you begin, have you experienced any of the following? If yes, seek doctor as soon as possible. 1: Night sweats? 2: Recent fever? 3: Change in bladder/bowel habits, more specifically urine retention/faecal incontinence? 4: Unexplained weight loss? 5: Cough more than 3 weeks duration +\- blood in sputum? 6: Pain down both legs? 7: Poor controlled leg movement? 8: Loss of feeling down both legs or around buttocks or inner surface of thighs?
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Stroke objective

Has the person had an acute stroke within last 24 hours? Any of these present: face droop, slurred speech, severe headache, one sided numbness?

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Stroke objective

Has the patient been cleared by a medical team for assessment?

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Stroke objective

Can the patient move their right leg and arm without issues?

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Stroke objective

Is the right leg or arm stiff to move?

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Stroke objective

Is the right leg or arm heavy and floppy?

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Stroke objective

Can the patient move their left leg and arm without issues?

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Stroke objective

Is their left leg or arm stiff to move?

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Stroke objective

Is their left leg or arm heavy and floppy?

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Stroke objective

Can they sit unaided and lean in all directions (sideways/backwards/forwards) without problem?

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Stroke objective

With their eyes closed can they feel the impaired limb being moved passively by another person?

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Stroke objective

With eyes closed, can they feel impaired limb being touched?

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Stroke objective

Can the affected shoulder be moved fully by another person?

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Stroke objective

Does the shoulder look out of place?

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Stroke objective

Is the shoulder painful?

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Stroke objective

Can the affected elbow be fully straightened?

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Stroke objective

Can the affected wrist be moved through full range?

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Stroke objective

Can the hand/fingers be fully opened?

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Stroke objective

Can the affected hip be moved fully through range?

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Stroke objective

Can the knee be moved fully through range?

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Stroke objective

Can the ankle be moved fully through range?

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Stroke objective

Can the patient roll to the left and right on a bed?

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Stroke objective

Can the patient lie on their back and lift their bottom?

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Stroke objective

Can the patient move from lying to sitting unaided?

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Stroke objective

Can the patient move from lying to sitting with assistance from one person?

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Stroke objective

Can the patient move from lying to sitting with assistance of 2 people?

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Stroke objective

Can the patient move from sit to stand unaided?

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Stroke objective

Can the patient move from sit to stand with assistance of 1 person? For a stroke patient, sitting to standing is best achieved slowly with two people to begin with, as blood pressure needs monitoring

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Stroke objective

Can the patient move from sit to stand with assistance of 2 people?

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Stroke objective

Can the patient stand and lean in all directions independently?

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Stroke objective

Can the patient walk unaided?

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Stroke objective

Can the patient walk with a stick/zimmer frame unaided?

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Stroke objective

Can the patient walk with assistance of one or two people?

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Stroke objective

Do they have an altered walking pattern (abnormal gait)?

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Stroke objective

Can they stand on affected leg and step with other leg?

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Objective notes alert

Things to observe:

Here, we outline the objective results of your assessment, the progress towards functional goals and any treatments performed. Include details of any interventions, as well as frequency, duration and equipment used. The therapist should indicate changes in the patient's status, as well as communication with colleagues, family or carers.

Try to avoid:

  • Giving no detail
  • Summary detail such as: "ROM exercises given"

essentially, note:

  • range of movement (split into passive and active)
  • muscle strength
  • neurological assessment
  • gait
  • function

Using notes:

Simply type a note and press "Enter" key. You can edit existing notes or delete a note. To delete all your notes, use "Clear". However, as this will remove all notes on this page it is advised to copy and paste them into a document and store them elsewhere before clearing them here.

Stroke Objective Assessment notes

 

my Objective notes symbol objective

(after listening to my patient's account and from observing all signs and clues given)

  • My observations are...

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