66% of people have concerns about the safety of their electronic health records.
There are many challenges regarding data management in the healthcare industry – and safety is among the biggest.
In the first half on 2019 alone, over 31 million patient records were compromised.
One of the tools that can help healthcare providers overcome the challenges of data collection and management are mobile forms.
Healthcare providers can use mobile forms to easily and securely create and manage bundles of data, such as head-to-toe assessments or annual physical exam checklists.
In this post, we will focus on the latter and explore what a comprehensive annual physical exam checklist should look like and why using doForms to create one can help ensure everything is covered and patient records are safe.
Table of Contents
What Is An Annual Physical Exam Checklist?
An annual physical exam checklist is a comprehensive, step-by-step guide to checking the health condition and overall wellbeing of a patient.
As the name suggests, an annual exam should be performed once a year to benchmark a patient’s health.
These exams can not only help keep the current health condition of a patient in check, but they can also identify early signs of serious chronic disease.
Annual physical exam checklists allow health care providers to perform the exams and analyze and store the results.
What Should A Complete Physical Exam Checklist Cover?
Since an annual physical exam is only performed once a year, it should be as comprehensive as possible.
Here are the points that the exam checklist should include:
#1: Medical History
Before the actual examination of the patient, it is crucial to establish the patient’s medical history.
The medical history section of the checklist should touch upon:
- Lifestyle and habits: diet, level of physical activity, substance abuse
- Family health history: cases of serious hereditary disease
- Medication and past treatments: including what they were administered for
By analyzing a patient’s medical history, you can predict the probability of them developing chronic or lifestyle-related diseases and administer preventive measures.
#2: Vital Signs
The second step on the checklist is to assess the patient’s vital signs, such as:
- Heart rate
- Blood pressure
- Body temperature
- Blood oxygen level
- Respiration rate
Those metrics should be recorded and benchmarked against the average results for the patient’s age and sex, as well as against the patient’s past measurements.
#3: Blood Test
An in-depth blood test can reveal underlying health issues that, otherwise, would’ve been hard to diagnose.
Because of this, it’s an essential part of an annual exam.
There are several types of blood tests that measure different blood components. However, for the purposes of the l exam, a complete blood count (CBC) is typically the most appropriate.
CBC measures the levels of key blood components, including:
- Red blood cells
- White blood cells
#4: Visual Exam
A visual examination of the patient is the fourth step of an annual checkup.
The point of the visual exam is quite self-explanatory – to assess the overall condition of the patient based on their physical appearance.
Some of the things to note during the visual exam are:
- Color and texture of the patient’s skin
- Appearance of the patient’s eyeballs
- Appearance of the patients hands and nails
#5: Physical Exam
The physical exam is the most comprehensive part of the annual checkup.
It usually includes an inspection of the following areas of the patient’s body:
- Heart and lungs using a statoscope to observe the heart rate and the lung function of the patient
- Head, neck and abdomen to check these areas for sensitivity or abnormalities
- Limbs and joints to examine whether they function properly
- Neurological responses using a small mallet on joint locations
- Skin to detect potential dermatological abnormalities
#6: Cancer Screening
Cancer screening is the final step of the exam checklist.
The exact screening procedure will depend on the specific kinds of cancer that the patent or the doctor wants to watch out for, based on factors such as sex, current physical condition, past medical history, and family medical history.
A cancer screening is an important part of the annual checkup, as it can help identify early symptoms of the disease, which can lead to earlier treatment and a better prognosis.
Men’s Physical Exam Checklist: What Focus On
While the main points of the checklist are the same for men and women, there are a few specific points to focus on when examining male patients.
#1: Prostate Disease
Around 25% of men over 55 suffer from prostate disease.
Since the prostate is a part of the male reproductive system, it is important to address prostate health whenever performing a physical exam on male patients.
The most common types of prostate disease are:
- Prostatitis (inflammation)
- Non-cancerous enlargement of the prostate
- Prostate cancer
While prostatitis and the non-cancerous enlargement of the prostate are not life-threatening conditions, prostate cancer can be.
An estimated 34,500 men will die from prostate cancer in 2022 in the United States. Thankfully, prostate cancer is easily detectable in early stages, which makes the outlook much more positive.
Some common symptoms of the prostate disease – including prostate cancer – are:
- Difficulties urinating
- Painful urinating
- Urge to urinate more frequently, especially during nighttime
- Weak urine flow
There are several ways of diagnosing prostate disease, including:
- Physical examination of the prostate
- Ultrasound exam
- Prostate-specific blood test
- Mid-stream urine test
- Prostate biopsy (if prostate cancer is suspected)
#2: Abdominal Aortic Aneurysm
An abdominal aortic aneurysm is a swelling of the abdominal section of the aorta – a condition with almost no apparent symptom that can be fatal if left unchecked.
Abdominal aortic aneurysms are 4 times more likely to occur in men. And while they usually occur without any specific symptoms, there are a few signs to watch out for, such as:
- Dull pain or discomfort in the chest or abdomen
- Pulsating feeling in the abdomen
- Weight loss or fever (if caused by infection)
Abdominal aortic aneurysms are usually diagnosed during:
- Abdominal ultrasound exam
- CT scan
- MRI scan
#3: Heart Disease
Heart disease kills 1 in 4 men in the United States.
It is the leading cause of death among males and often occurs without any symptoms or family history.
There are several kinds of hearts disease, such as:
- Atherosclerotic disease
- Heart arrythmia
- Valvular heart disease
The exact symptoms of heart disease depend on the specific kind of disease, but they may include:
- Chest pain or tightness, shortness of breath and numbness in the limbs for atherosclerotic disease
- Irregular heartbeat, heart palpitations and dizziness for arrythmia
- Fatigue, shortness of breath and chest pain for valvular heart disease
Each one of these types of heart disease can be diagnosed via:
- Holter Monitor
Women’s Physical Exam Checklist: What To Focus On
Just like with males, there are several specific diseases that more commonly affect women. As such, their monitoring should be included in annual physical exam checklists for women.
#1: Breast Cancer
Breast cancer is the second most common cancer and the second most common cause of cancer death among U.S. women.
Just like with other types of cancer, identifying it as early as possible is instrumental to successful treatment.
Here are the most common breast cancer symptoms:
- Lumps in the breast or armpit
- Irritation of breast skin
- Nipple discharge
The most common methods of diagnosing breast cancer are:
- Physical breast exam
- Breast ultrasound exam
- Breast biopsy
#2: Reproductive System Disease
There are several reproductive system diseases that exclusively affect women.
Conditions such as endometriosis, cervical cancer and uterine fibroids can pose a serious health threat, as well as increase the chances of infertility, pregnancy complications or miscarriage.
This is why these diseases should also be included in the women’s physical exam checklist.
Some common signs of reproductive system disease in women are:
- Pain in the abdomen or lower pelvic area
- Painful or heavy periods
- Frequent urination
- Feeling of pressure in the pelvic area
Ways of identifying reproductive system disease in women depend on the exact condition and include:
- Ultrasound exam
- Papanicolaou (Pap) test (for cervical cancer)
#3: Autoimmune Disease
78% of people affected by autoimmune disease are women.
While autoimmune diseases are often not life-threatening, they require constant monitoring to prevent complications.
This is why it’s a good idea for healthcare professionals to make autoimmune disease screening a part of their women’s exam checklist.
Autoimmune diseases are plentiful and range in symptoms and severity. Some of the more common conditions include:
- Sjögren’s syndrome
- Inflammatory bowel disease
- Celiac disease
- Hashimoto’s disease
Why Use doForms To Create Your Annual Physical Exam Checklist?
doForms offers a healthcare-specific mobile solution that healthcare providers can use to create, manage and share exam checklists.
Here are several advantages to using doForms for healthcare data management:
- HIPAA compliance
- Cloud-based data management for data access on the go via a mobile device
A mobile form-based annual physical exam checklist enables healthcare providers to record, store, and analyze the results of their patients’ annual checkups in a convenient and secure way.
A comprehensive annual exam checklist should cover:
- Patient’s medical history
- Patient’s vital signs
- Blood testing
- Visual testing
- Physical testing
- Cancer screening
With male patients, it is important to also focus on monitoring specific diseases that commonly affect men, such as:
- Prostate disease
- Abdominal aortic aneurysm
- Heart Disease
The same goes for female patients and diseases that tend to affect more women, including:
- Breast cancer
- Reproductive system disease
- Autoimmune disease
The healthcare-specific mobile form solution by doForms can be a powerful tool for creating and managing annual exam checklists thanks to its HIPAA compliance, high level of security, and straightforward user experience.