80%(10)8 out of 10 people found this document helpful
This preview shows page 1 - 5 out of 14 pages.
Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate: Patient InformationPatient InitialsAgeSexChief ComplaintPatient reports having discomfort in left hip when doing physical activities, otherwise no current complaints. Patient reports no medical history. Patient reports that he is followed by a physician and has regular yearly check-ups.History of Present Illness (HPI)Patient reports no medical history of illnesses.7 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsNo medications.AllergiesNo known drug or food allergies.1
Medical HX (PMH)ChildhoodNo medical history.AdultNo medical history.SurgicalNo surgical history.Ob/GynN/APsychiatricNo medical history.VaccinationsFluDate: Oct. 2018PneumovaxDate: N/ATetanusDate: Unknown—patient states is upto dateFamily HX (specify family member affected/age at death)Father: No medical history—AliveMother: No medical history—AliveSister: No medical history—AliveSister: No medical history—Alive Social/Environmental HXHTN-NoDM-NoCa-NoMI/CAD-NoCVA-NoTB-NoRenal dz-NoThyroid dz-NoSuicide-NoAlcoholism-NoSubstance abuse-NoBorn in:Edmond, OklahomaEducation:Bachelors DegreeOccupation: Software Architect Family situation:Married, currently lives in single family home.Transportation options:Owns owncareInsurance:Health Insurance throughoccupationNeighborhood:Lives in suburbs2
Language/Literacy:English, patientis able to read and writeAccess to emerging technologies: Yes.Interests/Hobbies:Cooking, being outside, playing and listening to musicReview of Systems (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; fevers-SkinRash; lumps; sores; itching; dryness; color change; Δ in hair/nails-HeadHeadache; head injury; dizziness-EyesVision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma-EarsHearing Δ; tinnitus; earaches; infections; discharge-Nose/SinusesColds; congestion; discharge; itching; hay fever; nosebleeds-ThroatBleeding gums; dentures; last dental 3