Tina Jones HEENT Objective Data Collection
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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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
