Objective Data Shadow Health – Samantha Monroe

Objective Data Shadow Health – Samantha Monroe

Objective Data Collection: 23 Of 23 (100%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed
 Growth Chart: Height & Weight
1 of 1 point
Weight Percentile (1/4 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Weight Growth Curve (1/4 point)
  •  Growth curve maintained
  •  Growth curve decline
Height Percentile (1/4 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Height Growth Curve (1/4 point)
  •  Growth curve maintained
  •  Growth curve declined
 Inspected Skin
1 of 1 point
Lesions (1/5 point)
  •  No visible lesions
  •  Lacerations/wounds
  •  Erythema
  •  Ecchymosis
  •  Birthmark
  •  Discolorations
Color (1/5 point)
  •  Consistent with ethnic background
  •  Jaundice
  •  Cyanosis
  •  Pallor
Texture (1/5 point)
  •  Smooth
  •  Rough
Temperature (1/5 point)
Skin Hydration (1/5 point)
  •  Elastic
  •  Elastic Tenting
  •  Sluggish Turgor
 Inspected General Appearance
1 of 1 point
Posture (1/2 point)
  •  Upright posture without tension or rigidity
  •  Bent or hunched posture, tension or rigidity
Clothing (1/2 point)
  •  Clean clothing, appropriate for age, fit, season and occasion
  •  Dirty, disheveled, or inappropriate to age, fit, season or occasion
 Assessed Cervical Spine RoM
1 of 1 point
Flexion (1/4 point)
  •  Expected range of motion (approx. 45)
  •  Reduced range of motion
Extension (1/4 point)
  •  Expected range of motion (approx. 45)
  •  Reduced range of motion
Lateral Bending (1/4 point)
  •  Expected range of motion (approx. 40) on both sides
  •  Reduced range of motion on right
  •  Reduced range of motion on left
Rotation (1/4 point)
  •  Expected range of motion (approx. 70) on both sides
  •  Reduced range of motion on right
  •  Reduced range of motion on left
 Assessed Spine Range of Motion
1 of 1 point
Rotation (1/1 point)
  •  Expected range of motion (approx. 75-90 degrees)
  •  Reduced flexion
 Assessed Wrist RoM
1 of 1 point
Left Extension (1/4 point)
  •  Expected range of motion (approx. 90 degrees)
  •  Reduced flexion
Right Extension (1/4 point)
  •  Expected range of motion (approx. 90 degrees)
  •  Reduced extension
Left Flexion (1/4 point)
  •  Expected range of motion (approx. 90 degrees)
  •  Reduced flexion
Right Flexion (1/4 point)
  •  Expected range of motion (approx. 90 degrees)
  •  Reduced flexion
 Assessed Elbow RoM
1 of 1 point
Left: Flexion And Extension (1/4 point)
  •  Expected range of motion (approx. flexion of 160 degrees and 180 degrees of full extension)
  •  Reduced Extension
  •  Reduced Flexion
Right: Flexion And Extension (1/4 point)
  •  Expected range of motion (approx. flexion of 160 degrees and 180 degrees of full extension)
  •  Reduced Extension
  •  Reduced Flexion
Left: Supination And Pronation (1/4 point)
  •  Expected range of motion (approx. pronation of 90 degrees and 90 degrees of supination)
  •  Reduced Pronation
  •  Reduced Supination
Right: Supination And Pronation (1/4 point)
  •  Expected range of motion (approx. pronation of 90 degrees and 90 degrees of supination)
  •  Reduced Pronation
  •  Reduced Supination
 Assessed Shoulder RoM
1 of 1 point
Adduction (1/3 point)
  •  Expected range of motion (approx. 50 degrees)
  •  Reduced range of motion
Abduction (1/3 point)
  •  Expected range of motion (approx. 50 degrees)
  •  Reduced range of motion
Strength (1/3 point)
  •  0 – No muscle contraction
  •  1 – Barely detectable contraction
  •  2 – Active movement with gravity eliminated
  •  3 – Active movement against gravity
  •  4 – Active movement against gravity and resistance
  •  5 – Active movement against full resistance without fatigue (normal)
 Assessed Trapezius Strength
1 of 1 point
Strength (1/1 point)
  •  0 – No muscle contraction
  •  1 – Barely detectable contraction
  •  2 – Active movement with gravity eliminated
  •  3 – Active movement against gravity
  •  4 – Active movement against gravity and resistance
  •  5 – Active movement against full resistance without fatigue (normal)
 Assessed Deltoid Strength And Shoulder Rotation
1 of 1 point
Strength & Rotation (1/3 point)
  •  Symmetric
  •  Asymmetric
Forward Flexion (1/3 point)
  •  Expected range of motion (approx. 180 degrees)
  •  Reduced range of motion
Extension (1/3 point)
  •  Expected range of motion (approx. 50 degrees)
  •  Reduced range of motion
 Assessed Hand/Finger RoM And Strength
1 of 1 point
Left (1/2 point)
  •  0 – No muscle contraction
  •  1 – Barely detectable contraction
  •  2 – Active movement with gravity eliminated
  •  3 – Active movement against gravity
  •  4 – Active movement against gravity and resistance
  •  5 – Active movement against full resistance without fatigue (normal)
Right (1/2 point)
  •  0 – No muscle contraction
  •  1 – Barely detectable contraction
  •  2 – Active movement with gravity eliminated
  •  3 – Active movement against gravity
  •  4 – Active movement against gravity and resistance
  •  5 – Active movement against full resistance without fatigue (normal)
 Assessed Symmetry of Extremities
1 of 1 point
Extremities (1/1 point)
  •  Symmetrical
  •  Asymmetrical
 Assessed Leg Symmetry, Knee or Ankle Effusion
1 of 1 point
Effusion (1/3 point)
  •  Present
  •  Not present
Leg Symmetry (1/3 point)
  •  Symmetric
  •  Asymmetric
Knee Symmetry (1/3 point)
  •  Symmetric
  •  Asymmetric
 Assessed Calf Symmetry, Leg Strength
1 of 1 point
Calf Muscles (1/2 point)
  •  Symmetric
  •  Asymmetric
Leg Strength (1/2 point)
  •  0 – No muscle contraction
  •  1 – Barely detectable contraction
  •  2 – Active movement with gravity eliminated
  •  3 – Active movement against gravity
  •  4 – Active movement against gravity and resistance
  •  5 – Active movement against full resistance without fatigue (normal)
 Tested Hip, Knee and Ankle Range of Motion
1 of 1 point
Hip Range Of Motion (1/3 point)
  •  Symmetric, full range of motion without limitations
  •  Asymmetric range of motion with limitations
Knee Range Of Motion (1/3 point)
  •  Symmetric, full range of motion without limitations
  •  Asymmetric range of motion with limitations
Ankle Range Of Motion (1/3 point)
  •  Symmetric, full range of motion without limitations
  •  Asymmetric range of motion with limitations
 Tested 6 Cardinal Fields of Vision
1 of 1 point
Cardinal Fields (1/2 point)
  •  No abnormal findings
  •  Nystagmus
  •  Fixed Pupil
Convergence (1/2 point)
  •  No 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
 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
 Romberg Test
1 of 1 point
Romberg (1/1 point)
  •  Maintains upright posture
  •  Difficulty remaining upright
 Auscultated Breath Sounds
1 of 1 point
Breath Sounds (1/2 point)
  •  Clear in all areas
  •  Diminished in some areas
  •  Absent in some areas
Adventitious Sounds (1/2 point)
  •  No adventitious sounds
  •  Wheezing
  •  Fine crackles
  •  Stridor
  •  Rhonchi
  •  Rales
 Auscultated Abdominal Aorta
1 of 1 point
Sounds (1/1 point)
  •  No bruit
  •  Bruit
 Auscultated Heart Sounds
1 of 1 point
Heart Sounds (1/3 point)
  •  S1 and S2 audible
  •  S1, S2, and S3 audible
  •  S1, S2 and S4 audible
  •  S1, S2, S3 and S4 audible
Extra Heart Sounds (1/3 point)
  •  No extra sounds
  •  Gallops
  •  Murmur
  •  Friction rub
  •  Valve clicks
Rate And Rhythm (1/3 point)
  •  Regular rate and rhythm
  •  Irregular rate and rhythm
  •  Arrhythmia
 Screened Adam’s Forward Bend
1 of 1 point
Iliac Crests (1/6 point)
  •  Equal height
  •  Unequal height
Scapula Prominence And Shape (1/6 point)
  •  Equal height
  •  Unequal height
Spine Contour (1/6 point)
  •  Expected curvature
  •  Decreased lordosis
  •  Increased lordosis
  •  Decreased kyphosis
  •  Increased kyphosis
Spine Symmetry (1/6 point)
  •  Symmetrical
  •  Asymmetrical
Waistline (1/6 point)
  •  Equal height
  •  Unequal height
Flexion (1/6 point)
  •  Expected range of motion (approx. 75-90 degrees)
  •  Reduced flexion

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