C350ADF.docx - Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date Patient Information Patient Initials

C350ADF.docx - Advanced Nursing Practice Field Experience...

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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date: Patient Information Patient Initials Age Sex Chief Complaint Patient 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 manifestations Medications No medications. Allergies No known drug or food allergies. 1
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Medical HX (PMH) Childhood No medical history. Adult No medical history. Surgical No surgical history. Ob/Gyn N/A Psychiatric No medical history. Vaccinations Flu Date: Oct. 2018 Pneumovax Date: N/A Tetanus Date: Unknown— patient states is up to date Family HX (specify family member affected/age at death) Father: No medical history—Alive Mother: No medical history—Alive Sister: No medical history—Alive Sister: No medical history—Alive Social/Environmental HX HTN-No DM-No Ca-No MI/CAD-No CVA-No TB-No Renal dz-No Thyroid dz-No Suicide-No Alcoholism-No Substance abuse- No Born in: Edmond, Oklahoma Education: Bachelors Degree Occupation: Software Architect Family situation: Married, currently lives in single family home. Transportation options: Owns own care Insurance: Health Insurance through occupation Neighborhood: Lives in suburbs 2
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Language/Literacy: English, patient is able to read and write Access to emerging technologies: Yes. Interests/Hobbies: Cooking, being outside, playing and listening to music 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 3
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exam; sore tongue; dry mouth; sore throats; hoarse - Neck Lumps; swollen glands; goiter; pain; neck stiffness - Breasts Lumps; pain; discomfort; nipple discharge - Pulmonar y Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains - Cardiac Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema - G/I Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance - Urinary Frequency; nocturia; urgency; dysuria; hematuria; incontinence MALES : caliber of urinary stream; hesitancy; dribbling - G/U (General) Sexual habits; interest; function; satisfaction; use of birth control
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