Comprehensive Health Assessment Documentation Form.docx - Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form

Comprehensive Health Assessment Documentation Form.docx -...

This preview shows page 1 - 5 out of 11 pages.

Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:9/23/19 Patient Information Patient Initials G.Y. Age 29 Sex Female Chief Complaint Annual Comprehensive Health Assessment History of Present Illness (HPI) Denies any present illness 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Denies any medication prescribed or over the counter Allergies No Known Allergies 1
Image of page 1
Medical HX (PMH) Childhood None Adult None Surgical None Ob/Gyn LMP: 9/22/2019 Psychiatric None Vaccinations Flu Date:Fall 2018 Pneumovax Date:not received Tetanus Date:2016 Family HX (specify family member affected/age at death) Mother-Healthy no medical problems Father-Died age 71- Cancer Social/Environmental HX HTN DM Ca MI/CAD CVA TB Renal dz Thyroid dz Suicide Alcoholism-drinks socially one wine glass per week Substance abuse Born in: Los Angeles, CA Education: Undergraduate Occupation: ASL interpreter Family situation: Siblings and mother live close by. Lives with boyfriend Transportation options: Car Insurance: Kaiser, provided by employer Neighborhood: Low crime rate, clean Language/Literacy: English, Armenian, ASL Access to emerging technologies: Yes Interests/Hobbies: Hiking and Bike riding 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) 2
Image of page 2
Concerning Symptom Findings General Wgt Δ; weakness; fatigue; fevers negative Skin Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails negative Head Headache; head injury; dizziness negative Eyes Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma negative Ears Hearing Δ; tinnitus; earaches; infections; discharge negative Nose/ Sinuses Colds; congestion; discharge; itching; hay fever; nosebleeds negative Throat Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse negative Neck Lumps; swollen glands; goiter; pain; neck stiffness negative Breasts Lumps; pain; discomfort; nipple discharge negative Pulmonar y Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains negative Cardiac Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema negative G/I Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance negative Urinary Frequency; nocturia; urgency; dysuria; hematuria; incontinence MALES : caliber of urinary stream; hesitancy; dribbling negative G/U Sexual habits; interest; function; 3
Image of page 3
(General) satisfaction; use of birth control methods; HIV exposure negative Male G/U Discharge from or sores on penis; testicular pain/masses Patient is Female Female G/U Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP Vaginal discharge; itching; sores; lumps Menopause; hot flashes; post- menopausal bleeding;
Image of page 4
Image of page 5

You've reached the end of your free preview.

Want to read all 11 pages?

  • Spring '16
  • Shelley Ashby

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture