Objective assessment Objective notes

seek medical help if the following apply

  • 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 confirm that you have checked that none of the above apply

translate

      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?
back        

Objective Diagnosis:

please make a note of your diagnosis number and name that appears here before clicking the 'next' button

 

Amputee objective analysis

Do you know the cause of the amputation?

back        

Amputee objective analysis

Does the patient have co-morbidities that might affect prosthetic use?

back        

Amputee objective analysis

Does the patient understand and retain new information? a friend may be necessary or a relative may be vital

back        

Amputee objective analysis

Is the stump healthy? check for signs of vascular disease or infection

back        

Amputee objective analysis

Is the stump oedematous? check for signs of oedema by pressing gently with flat of thumb

back        

Amputee objective analysis

Is the scar healthy?

back        

Amputee objective analysis

Is the stump painful?

back        

Amputee objective analysis

Does either hip have reduced active/passive ROM?

back        

Amputee objective analysis

Does either hip have reduced muscle power?

back        

Amputee objective analysis

Does either knee have reduced active/passive ROM?

back        

Amputee objective analysis

Does either knee have reduced power?

back        

Amputee objective analysis

Does the ankle have reduced ROM?

back        

Amputee objective analysis

Does the ankle have reduced power?

back        

Amputee objective analysis

Does either arm have reduced ROM at either shoulder, elbow, wrist or hand?

back        

Amputee objective analysis

Does either arm have reduced power at the shoulder, elbow, wrist or hand?

back        

Amputee objective analysis

Does the patient have good hand dexterity?

back        

Amputee objective analysis

Is the contra-lateral foot healthy?

back        

Amputee objective analysis

Based on this on-going assessment Is a prosthesis suitable for the patient?

back        

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.

Amputee 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...

symbol analysis Save   |   symbol analysis Clear

(use info button below for guidance)

back