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General Assessment
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| Vital Signs
Numeric (e.g., BPM, mmHg)
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| Pain
Numeric (0-10)
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| Level of Consciousness
Scale (GCS)
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Neurological
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| Pupil Reaction
Scale (Brisk, Sluggish, None)
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| Motor Response
Scale (Normal, Weak, Absent)
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| Speech
Scale (Clear, Slurred, Absent)
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Cardiovascular
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| Heart Rate
Numeric (BPM)
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| Blood Pressure
Numeric (mmHg)
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| Peripheral Pulses
Scale (Bounding, Normal, Weak)
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Respiratory
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| Respiratory Rate
Numeric (RPM)
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| Oxygen Saturation
Numeric (%)
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| Breath Sounds
Scale (Clear, Wheezing, Crackles)
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Gastrointestinal
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| Bowel Sounds
Scale (Hypoactive, Normal, Hyperactive)
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| Abdominal Tenderness
Scale (Yes/No)
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| Nausea/Vomiting
Scale (None, Mild, Severe)
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Musculoskeletal
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| Range of Motion
Scale (Full, Limited, None)
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| Strength
Scale (Normal, Weak, Absent)
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| Gait
Scale (Stable, Unsteady)
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Integumentary
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| Skin Integrity
Scale (Intact, Impaired)
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| Wounds
Scale (Present, Healing, Infected)
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| Edema
Scale (None, Mild, Severe)
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