Documentation Of The Respiratory Single Organ System Exam

Single Organ System Exam Respiratory

Created by The Lung Doctor

Single Organ System Exam Respiratory Comprehensive Level Perform and document ALL elements in the following organ systems

      

Constitutional ENT Inspection Neck Respiratory Cardiovascular Gastrointestinal Lymphatic

Created by The Lung Doctor

Perform and document at least 1 element in each of the following

Musculoskeletal Extremities Skin Neurologic

Single Organ System Exam Respiratory Constitutional Document at least 3 vital signs as follows  Blood Pressure – Sitting OR Standing

 Blood Pressure – Lying

 Pulse – Rate AND Regularity

 Temperature  Height  Weight

Note:

May be measured and recorded by ancillary staff

Created by The Lung Doctor

Single Organ System Exam Respiratory Ears, Nose, Mouth, Throat Inspection of nasal mucosa, septum, turbinates Inspection of teeth and gums Examination of oropharynx  Oral mucosa, hard and soft palates, tongue, tonsils, and posterior pharynx

Created by The Lung Doctor

Single Organ System Exam Respiratory Neck Examination of neck  Masses, overall appearance, symmetry, tracheal position, crepitus

Examination of thyroid  Enlargement, tenderness, mass

Examination of jugular veins  Distension, a, v or cannon a waves

Created by The Lung Doctor

Single Organ System Exam Respiratory Respiratory Inspection of chest with notation of symmetry and expansion Assessment of respiratory effort  Intercostal retractions, accessory muscle use, and diaphragmatic movement

Percussion of chest  Dullness, flatness, hyperresonance

Palpation of chest  Tactile fremitus

Auscultation of lungs  Breath sounds, adventitious sounds, rubs Created by The Lung Doctor

Single Organ System Exam Respiratory Cardiovascular Auscultation of heart sounds, abnormal sounds and murmurs Examination of peripheral vascular system by observation and palpation  Swelling and varicosities  Pulses, temperature, edema, tenderness

Created by The Lung Doctor

Single Organ System Exam Respiratory Gastrointestinal (Abdominal) Examination of abdomen with notation of presence or absence of masses or tenderness Examination of liver and spleen

Created by The Lung Doctor

Single Organ System Exam Respiratory Lymphatic Palpation of lymph nodes  Neck  Groin  Axilla  Other location

Note:

Exam of at least 2 locations must be documented

Created by The Lung Doctor

Single Organ System Exam Respiratory Perform and document at least 1 of the following

Musculoskeletal Assessment of muscle strength and tone with notation of any atrophy and abnormal movements  Flaccid, cogwheel, spastic

Examination of gait and station

Created by The Lung Doctor

Single Organ System Exam Respiratory Perform and document at least 1 of the following

Extremities Inspection and palpation of digits and nails  Clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes

Created by The Lung Doctor

Single Organ System Exam Respiratory Perform and document at least 1 of the following

Skin Inspection and/or palpation of skin and subcutaneous tissue  Rashes, lesions, ulcers

Created by The Lung Doctor

Single Organ System Exam Respiratory Perform and document at least 1 of the following

Neurological/Psychiatric Brief assessment of mental status  Include orientation to person, time and place  Include mood and affect – Anxiety, depression, agitation

Created by The Lung Doctor