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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Objective Diagnosis:

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

 

SCI objective assessment

Has an accident just happened?

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SCI objective assessment

Can the patient actively move their upper limbs at all?

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SCI objective assessment

Can the patient bend their elbow towards their face ?

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SCI objective assessment

Can the patient bend their wrist up?

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SCI objective assessment

Can the patient straighten their arm at the elbow?

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SCI objective assessment

Can the patient bend their fingers?

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SCI objective assessment

Can the patient move their fingers side to side?

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SCI objective assessment

Does the patient have sensation at their nipple line? (upper thoracic)

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SCI objective assessment

Does the patient have sensation at their navel line? (lower thoracic)

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SCI objective assessment

Can the patient bring their knees up to their chest while lying on their back?

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SCI objective assessment

Can the patient straighten their knee? feel for flickers of muscle activity as well

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SCI objective assessment

Can they dorsiflex their ankle?

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SCI objective assessment

Can they pull up their big toe?

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SCI objective assessment

Can they plantarflex?

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SCI objective assessment

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      15 Can they sit unaided?
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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.

Spinal 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)

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