Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:__________ Patient Information Patient Initials Age Sex Chief Complaint History of Present Illness (HPI) 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Allergies Medical HX (PMH) 1
Childhood Adult Surgical Ob/Gyn Psychiatric Vaccinations Flu Date: Pneumovax Date: Tetanus Date: Family HX (specify family member affected/age at death) Social/Environmental HX HTN DM Ca MI/CAD CVA TB Renal dz Thyroid dz Suicide Alcoholism Substance abuse Born in: Education: Occupation: Family situation: Transportation options: Insurance: Neighborhood: Language/Literacy: Access to emerging technologies: Interests/Hobbies: 2
Review of Systems (ROS) List findings, or check as negative. (If you have a positive finding, then describe its seven attributes in the HPI or PMH) Concerning Symptom Findings General Wgt Δ; weakness; fatigue; fevers Skin Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails Head Headache; head injury; dizziness Eyes Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma Ears Hearing Δ; tinnitus; earaches; infections; discharge Nose/ Sinuses Colds; congestion; discharge; itching; hay fever; nosebleeds Throat Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse Neck Lumps; swollen glands; goiter; pain; neck stiffness
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- Spring '16
- Shelley Ashby
- Nursing, HPI, pulse