Tina Jones HEENT Objective Data Collection
Objective Data Collection: 24.59 of 25 (98.36%)
- Correct
- Partially correct
- Incorrect
- Missed
Inspected head and face
1 of 1 point
Skull Symmetry (1/3 point)
- Symmetric
- Asymmetric
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WE GUARANTEE A DCE SCORE OF ABOVE 95% AND HANDLE THE SOAP NOTE
Facial Feature Symmetry (1/3 point)
- Symmetric
- Asymmetric
Appearance (1/3 point)
- No visible abnormal findings
- Rash
- Papules, pustules, or comedones
- Skin growths (freckles, moles, or birthmarks)
- Excessive hair growth
- Evidence of skin trauma (scar, laceration, or bruising)
- Red, chapped nose
- Tina Jones HEENT Objective Data Collection
Inspected eyes and orbital area
0.75 of 1 point
Orbital Area (1/4 point)
- No visible abnormal findings
- Ptosis
- Eyelid edema
- Lesion
- Allergic shiners
Sclera (No point)
- White
- Injection
- Icterus
Conjunctiva (1/4 point)
- Moist and pink
- Pale
- Dry appearance
- Erythema
- Edema
Conjunctival Discharge (1/4 point)
- No discharge
- Clear, watery discharge
- Purulent discharge
Inspected nasal cavities
1 of 1 point
Color (1/4 point)
- Pink
- Pale
- Erythemic
- Bluish
Discharge (1/4 point)
- No discharge
- Clear discharge
- Bloody discharge
- Purulent discharge
Turbinate Patency (1/4 point)
- Patent
- Decreased patency
- Not patent
Observations (1/4 point)
- No additional visible abnormal findings
- Foreign body present
- Polyp
- Septum perforated
- Septum deviated
- Lesion
Inspected ears
1 of 1 point
Right: Auditory Canal Color (1/10 point)
- Pink
- Red
- Pallor
Right: Tympanic Membrane Color (1/10 point)
- Pearly gray
- Red
- Opaque
- Yellow
- Not visible because of cerumen
Right: Tympanic Membrane Appearance (1/10 point)
- No visible abnormal findings
- Fluid observed
- Visible scars
- Bulging
- Perforation
- Retraction
Right: Cone Of Light (1/10 point)
- 5:00
- Cone of light distorted
Right: Discharge (1/10 point)
- No discharge
- Cerumen
- Clear discharge
- Bloody discharge
- Purulent discharge
Left: Auditory Canal Color (1/10 point)
- Pink
- Red
- Pallor
Left: Tympanic Membrane Color (1/10 point)
- Pearly gray
- Red
- Opaque
- Yellow
- Not visible because of cerumen
Left: Tympanic Membrane Appearance (1/10 point)
- No visible abnormal findings
- Fluid observed
- Visible scars
- Bulging
- Perforation
- Retraction
Left: Cone Of Light (1/10 point)
- 7:00
- Cone of light distorted
Left: Discharge (1/10 point)
- No discharge
- Cerumen
- Clear discharge
- Bloody discharge
- Purulent discharge
Inspected mouth and throat
0.17 of 1 point
Oral Mucosa (1/6 point)
- Moist and pink
- Dry appearance
- Erythemic
Tonsils (No point)
- No visible abnormal findings
- Edema
- Erythema
Tonsil Grade (No point)
- 0: Tonsils fit within tonsillar fossa
- 1+: Tonsils <25% of space between pillars
- 2+: Tonsils <50% of space between pillars
- 3+: Tonsils <75% of space between pillars
- 4+: Tonsils >75% of space between pillars
- Tina Jones HEENT Objective Data Collection
Posterior Oropharynx Color (No point)
- Pink
- Erythemic
Posterior Oropharynx Texture (No point)
- No abnormal findings
- Cobblestoning
- Exudate
Post Nasal Drip (No point)
- No discharge
- Clear discharge
- Purulent discharge
Inspected neck
1 of 1 point
Symmetry (1/2 point)
- Symmetric
- Asymmetric
Appearance (1/2 point)
- No visible abnormal findings
- Swelling
- Visible pulsation
- Visible mass
- Discoloration
Palpated scalp
1 of 1 point
Tenderness (1/2 point)
- None reported
- Tenderness reported
Observations (1/2 point)
- No additional abnormal findings
- Balding or thinning areas in hair distribution
- Palpable masses
Palpated sinuses
1 of 1 point
Frontal (1/2 point)
- None reported
- Tenderness reported
Maxillary (1/2 point)
- None reported
- Tenderness reported
Palpated temporal arteries
1 of 1 point
Right: Vibration (1/4 point)
- No thrill
- Thrill
Right: Intensity (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Left: Vibration (1/4 point)
- No thrill
- Thrill
Left: Intensity (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Palpated carotid arteries
1 of 1 point
Right: Vibration (1/4 point)
- No thrill
- Thrill
Right: Intensity (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Left: Vibration (1/4 point)
- No thrill
- Thrill
Left: Intensity (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Palpated jaw
1 of 1 point
Observations (1/1 point)
- No palpable abnormal findings
- Limited range of motion
- Popping or clicking
Palpated lymph nodes
1 of 1 point
Head And Neck (1/3 point)
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
Supraclavicular (1/3 point)
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
Axillary (1/3 point)
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
Palpated thyroid gland
1 of 1 point
Observations (1/2 point)
- No palpable abnormal findings
- Nodules
- Enlarged
- Irregular
Tenderness (1/2 point)
- None reported
- Tenderness reported
Auscultated breath sounds
1 of 1 point
Breath Sounds (1/3 point)
- Present in all areas
- Diminished in some areas
- Absent in some areas
Adventitious Sounds (1/3 point)
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
Location (1/3 point)
- All areas clear
- Adventitious sounds in anterior right upper lobe
- Adventitious sounds in anterior right middle lobe
- Adventitious sounds in anterior right lower lobe
- Adventitious sounds in anterior left upper lobe
- Adventitious sounds in anterior left lower lobe
- Adventitious sounds in posterior right upper lobe
- Adventitious sounds in posterior right lower lobe
- Adventitious sounds in posterior left upper lobe
- Adventitious sounds in posterior left lower lobe
- Tina Jones HEENT Objective Data Collection
Auscultated temporal arteries
1 of 1 point
Right (1/2 point)
- No bruit
- Bruit
Left (1/2 point)
- No bruit
- Bruit
Auscultated carotid arteries
1 of 1 point
Right (1/2 point)
- No bruit
- Bruit
Left (1/2 point)
- No bruit
- Bruit
Tested pupillary reaction
1 of 1 point
Observations With Penlight (1/1 point)
- No visible abnormal findings (PERRL)
- Unequal
- Irregular
- Miosis
- Mydriasis
- Non-reactive to light
Tested extraocular eye movements
1 of 1 point
Cardinal Fields (1/2 point)
- No visible abnormal findings
- Nystagmus
- Fixed pupil
Convergence (1/2 point)
- No visible abnormal findings
- Unequal bilaterally
- Fixed pupil
Tested peripheral vision
1 of 1 point
Observations (1/1 point)
- No abnormal findings
- Reduced right visual field
- Reduced left visual field
Examined fundus with ophthalmoscope
1 of 1 point
Right: Retina (1/4 point)
- No visible abnormal findings
- Myelinated nerve fibers
- Papilledema
- Glaucomatous cupping
- Drusen bodies
- Cotton wool bodies
- Hemorrhage
Right: Disc Margin (1/4 point)
- Sharp
- Blurred
Left: Retina (1/4 point)
- No visible abnormal findings
- Myelinated nerve fibers
- Papilledema
- Glaucomatous cupping
- Drusen bodies
- Cotton wool bodies
- Hemorrhage
Left: Disc Margin (1/4 point)
- Sharp
- Blurred
Tested visual acuity
1 of 1 point
Right (1/2 point)
- 20/100
- 20/70
- 20/50
- 20/40
- 20/30
- 20/25
- 20/20
- 20/15
- 20/13
- 20/10
Left (1/2 point)
- 20/100
- 20/70
- 20/50
- 20/40
- 20/30
- 20/25
- 20/20
- 20/15
- 20/13
- 20/10
Performed Weber test
1 of 1 point
Results (1/1 point)
- Normal
- Conductive or sensorineural loss
Performed Rinne test
1 of 1 point
Right (1/2 point)
- Normal
- Conductive loss
Left (1/2 point)
- Normal
- Conductive loss
Performed whisper test
1 of 1 point
Right (1/2 point)
- Normal
- Unable to hear whispered words
Left (1/2 point)
- Normal
- Unable to hear whispered words
Tested gag reflex
1 of 1 point
Observations (1/1 point)
- Intact
- Absent
- Hypersensitive