Introduction/General Survey

Caring/Empathy - What questions should I ask?

"What matters most to you today?" "How are you doing?" "Is there anything you're concerned about?" "Do you have any questions?"

Patient Identification

Knock, introduce yourself, and identify the patient using two identifiers.

Explaining the Procedure

Explain what you will be doing and provide privacy.

Hand Hygiene and PPE

Perform hand hygiene, apply appropriate PPE, and wear gloves for the remainder of the exam per rubric.

Patient Comfort and Safety

Maintain comfort, privacy, and safety throughout the assessment.

Allergies

Ask about allergies and any reactions.

Level of Consciousness (LOC)

Alert, responsive, lethargic, or unresponsive.

Orientation x4

Person, place, time, and situation.

Facial Expression/Affect

Assess for calmness or distress, including respiratory, cardiac, pain, or emotional distress.

Hygiene and Grooming

Assess body odor, grooming, and appropriate dress.

Vital Signs

Assess BP, HR, RR, temperature, oxygen saturation, and pain. Verbalize which vital signs are needed.

Normal General Survey Findings

Patient is alert, oriented x4, calm, well groomed, and vital signs are within normal limits.