C350 documentation paper - Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Amanda Owens Date Patient

C350 documentation paper - Advanced Nursing Practice Field...

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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormAmanda OwensDate: December 26, 2016Patient InformationPatient InitialsJ.O.Age35SexMaleChief ComplaintRoutine Annual ExamHistory of Present Illness (HPI)35 year old presents for routine annual exam. No present illness or complaint.7 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsNoneAllergiesNo known drug allergies1
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Medical HX (PMH)ChildhoodNo significant findingsAdultNo significant findingsSurgicalNoneOb/GynN/APsychiatricNo significant findingsVaccinationsFluDate:10/1/16PneumovaxDate: NoneTetanusDate: 7/15/10Family HX (specify family member affected/age at death)No significant findings. All family is alive and without medical problems per patient.Social/Environmental HXHTNDMCaMI/CADCVATBN/ARenal dzThyroid dzSuicideAlcoholismSubstance abuseN/ABorn in: Las VegasEducation: Associate DegreeOccupation: Police OfficerFamily situation: Married w/2 kidsTransportation options: Drive SUVInsurance: Double insuredNeighborhood: Upscale Urban neighborhoodLanguage/Literacy: EnglishAccess to emerging technologies: Cell phone, computer, internet access, ability to afford technologyInterests/Hobbies: Outdoor activities, hunting, working out2
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Review of Symptoms (ROS)List findings, or check as negative.(If you have a positive finding, then describe its seven attributes inthe HPI or PMH)Concerning SymptomFindingsGeneralWgt Δ; weakness; fatigue; feversNegativeSkinRash; lumps; sores; itching; dryness; color change; Δ in hair/nailsNegative HeadHeadache; head injury; dizzinessNegativeEyesVision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotomaNegativeEarsHearing Δ; tinnitus; earaches; infections; dischargeNegativeNose/SinusesColds; congestion; discharge; itching; hay fever; nosebleedsNegativeThroatBleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarseNegativeNeckLumps; swollen glands; goiter; pain; neck stiffnessNegativeBreastsLumps; pain; discomfort; nipple dischargeNegativePulmonaryCough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic painsNegativeCardiacChest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edemaNegativeG/IAppetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intoleranceNegative3
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UrinaryFrequency; nocturia; urgency; dysuria;hematuria; incontinenceMALES: caliber of urinary stream; hesitancy; dribblingNegativeG/U (General)Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposureNegativeMale G/UDischarge from or sores on penis; testicular pain/massesNegativeFemale G/UMenarche; frequency/duration of menses; dysmenorrhea; PMS
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  • Spring '16
  • Shelley Ashby
  • Nursing, pulse, comprehensive health assessment, significant findings, routine annual exam , C350 Wgu

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