Here's the one I use for lab in Phys Assessment:
General Survey: facial expression, position, LOC, color, nutritional status, speech, hearing, hygeine
Vital Signs: Temp, Pulse(rate/reg), Resp effort, BP (avoid the IV), Sat (RA or on 02), Pain scale
Neuro: GCS, PERRL, muscle strength (R vs.L), ptosis, facial droop, sensation, communication, swallowing
needs? assist with eating or communication?
RespSys: 02use, resp effort, CTA?, cough, characteristics of mucus
needs? Incen Spirometer, cough and deep breath?
Cardio: peripheral pulses, RvsL, apical pulse (rate/reg), cap refill, ankles and shins for edema, IV sol & rate
needs? elevate feet, change IV site or tubing
Abd: contour, BSx4, palpate for tenderness, bowel and bladder hx
needs? stool softener, BSC, catheter care?
Skin: color, temp, w/d, turgor, integrity, lesions, surgical sites, dressings, check Teds or sequential stockings
needs? frequent linen changes, bathing, turning
Activity: bedrest to independence, toleration of movement, balance, SOB, equipment needed, trapeze, walker, cane