Schizophrenia Eric Ford Shadow health Objective data
Objective Data Collection: 21 of 21 (100%)
Correct
Partially correct
Incorrect
Missed
Assessed Vitals
1 of 1 point
Temperature
(1/5 point)
Normothermic
Hyperthermic
Hypothermic
Blood Pressure
(1/5 point)
Normotensive
Hypertensive
Hypotensive
Heart Rate
(1/5 point)
Normal
Tachycardic
Bradycardic
Respiratory Rate
(1/5 point)
Normal
Tachypnea
Bradypnea
O2 Saturation
(1/5 point)
Normal
Hypoxemia
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 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
Arrhythmia
Inspected Upper Extremities for Self-harm or Abuse
1 of 1 point
Observations
(1/3 point)
No visible evidence of self-harm or abuse
Evidence of self-harm
Evidence of abuse
Wounds Or Scars
(1/3 point)
No visible wounds or scars
Wound visible
Scar visible
Location Of Visible Abnormality
(1/3 point)
No visible abnormality
Right upper arm
Right lower arm
Right wrist
Right hand
Left upper arm
Left lower arm
Left wrist
Left hand
Inspected Involuntary Facial and Oral Movements
1 of 1 point
Observations Of Involuntary Movement
(1/1 point)
Normal
Frowning, smiling, or grimacing
Clenching or biting
Puckering or smacking lips
Lateral oral movement
Excessive blinking
Periorbital movement
Inspected Involuntary Movements of Upper Extremities
1 of 1 point
Observations
(1/1 point)
Normal
Choreic movements (rapid, irregular movements)
Athetoid movements (repetitive, rhythmic movements)
Inspected Involuntary Movements of Lower Extremities
1 of 1 point
Observations
(1/1 point)
Normal
Lateral knee movement
Foot tapping
Heel dropping
Foot squirming
Inversion and eversion of foot
Schizophrenia Eric Ford Shadow health Objective data
Inspected Involuntary Movements of Torso
1 of 1 point
Observations
(1/1 point)
Normal
Rocking
Twisting
Squirming
Pelvic gyration
Assessed General Appearance
1 of 1 point
Eye Contact
(1/4 point)
Direct eye contact
Indirect or no eye contact
Posture
(1/4 point)
Upright posture without tension or rigidity
Bent or hunched posture, tension, or rigidity
Schizophrenia Eric Ford Shadow health Objective data
Clothing
(1/4 point)
Clean clothing, appropriate to age, fit, season and occasion
Dirty, disheveled, or inappropriate to age, fit, season, or occasion
Schizophrenia Eric Ford Shadow health Objective data
Grooming
(1/4 point)
Demonstrates an appropriate level of grooming
Signs indicating lack of grooming or self-care
Assessed Attitude Toward Medical Staff
1 of 1 point
Attitude Toward Medical Staff
(1/1 point)
Generally open and cooperative
Generally suspicious, guarded, or evasive
Assessed Speech
1 of 1 point
Rate
(1/3 point)
Demonstrates appropriate or expected rate of speech
Excessively slow or rapid rate of speech
Volume
(1/3 point)
Demonstrates appropriate or expected speech volume
Excessively loud or soft speech volume
Articulation
(1/3 point)
No appreciable issues with articulation
Issues with articulation, slurring, or stutters
Assessed Mood and Affect
1 of 1 point
Mood
(1/2 point)
Stable mood with little or no fluctuation throughout the interview
Frequent and appreciable mood changes throughout the interview
Affect
(1/2 point)
Expansive affect (excessively cheerful affect characterized by contagious laughter or smiling)
Blunted or flat affect (little to no variation of expression regardless of conversation topic)
Schizophrenia Eric Ford
Shadow health
Objective data
Assessed Thought Process
1 of 1 point
Thought Process
(1/1 point)
No presence of thought process disturbances
Presence of rapid thinking, disorganized or illogical flow of thought, “word salad,” neologisms, echolalia, or clanging associations
Assessed Thought Content
1 of 1 point
Thought Content
(1/2 point)
No presence of thought content disturbances
Presence of delusions, obsessive or intrusive thoughts, or suicidal or homicidal ideation
Perceptual Disturbances
(1/2 point)
No presence of perceptual disturbances
Presence of auditory or visual hallucinations
Confirmed Orientation
1 of 1 point
To Person
(1/4 point)
Oriented to person
Not oriented to person
To Place
(1/4 point)
Oriented to place
Not oriented to place
To Time
(1/4 point)
Oriented to time
Not oriented to time
To Situation
(1/4 point)
Oriented to situation
Not oriented to situation
Assessed Serial Sevens
1 of 1 point
Serial Sevens
(1/1 point)
Able to complete the series
Unable to complete the series
Assessed Abstract Thinking
1 of 1 point
Abstract Thinking
(1/1 point)
Demonstrates abstract thinking with similarities test
Demonstrates concrete thinking with similarities test
Assessed Memory
1 of 1 point
Memory
(1/1 point)
Remote and immediate memory intact
Remote or immediate memory not intact
Assessed Visuospatial Ability
1 of 1 point
Visuospatial Ability
(1/1 point)
Visuospatial ability intact for interlocking shapes test
Visuospatial ability impaired with interlocking shapes test
Assessed Insight
1 of 1 point
Insight
(1/1 point)
Demonstrates full awareness of illness and willingness to seek treatment
Demonstrates limited or no awareness of illness and/or is unwilling to seek treatment
Schizophrenia Eric Ford Shadow health Objective data
Assessed Judgment
1 of 1 point
Judgment
(1/1 point)
Demonstrates good judgment
Judgment poor or impaired judgment
Schizophrenia Eric Ford Shadow health Objective data
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