Advanced Nursing Practice Field Experience
Comprehensive Health Assessment Documentation Form
Date:_9/22/2019_____
Patient Information
Patient Initials
RM
Age
45
Sex
Female
Chief Complaint
Patient presents today with request for a yearly physical.
History of Present Illness (HPI)
Patient present for physical, denies any health problems or needs.
7 attributes of a symptom: location, quality, quantity/severity, timing, setting,
remitting/exacerbating factors, associated manifestations
Medications
Patient does not take any medications.
Allergies
NKA
Medical HX (PMH)
Childhood
Patient denies
Adult
Patient denies
Surgical
Patient denies
Ob/Gyn
Patient denies problem, unknown if patient is in
care of OB/GYN
1
Psychiatric
Patient denies problems
Vaccinations
Flu
Date: 2019
Pneumovax
Date: 2019
Tetanus
Date: 2019
Family HX (specify family member affected/age at death)
Patient denies any family HX when asked
Social/Environmental HX
HTN
DM
Ca
MI/CAD
CVA
TB
Denies All
Renal dz
Thyroid dz
Suicide
Alcoholism
Substance abuse
Denies all
Born in: unknown
Education:
associates degree
Occupation:
RN
Family situation:
lives at home
with husband
Transportation options:
patient has
car
Insurance:
patient reports having
insurance
Neighborhood:
patient lives in
rural area
Language/Literacy:
patient speaks
English, college degree
Access to emerging technologies:
patient does have access to
various
technologies due to
occupation
Interests/Hobbies:
unknown
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
Patient denies
Skin
Rash; lumps; sores; itching; dryness;
color change; Δ in hair/nails
Patient denies
Head
Headache; head injury; dizziness
Patient denies
Eyes
Vision Δ; corrective lenses; last eye
exam; pain; redness; excessive
tearing; double vision; blurred vision;
scotoma
Patient does wear
corrective lenses and
states recently had eye
exam; date unknown.
Denies any changes
with vision, pain, or
redness
Ears
Hearing Δ; tinnitus; earaches;
infections; discharge
Patient denies
Nose/
Sinuses
Colds; congestion; discharge; itching;
hay fever; nosebleeds
Patient denies
Throat
Bleeding gums; dentures; last dental
exam; sore tongue; dry mouth; sore
throats; hoarse
Patient denies
Neck
Lumps; swollen glands; goiter; pain;
neck stiffness
Patient denies
Breasts
Lumps; pain; discomfort; nipple
discharge
Patient denies
3
Pulmonar
y
Cough—productive/non-productive;
hemoptysis; dyspnea; wheezing;
pleuritic pains
Patient denies
Cardiac
Chest pain or discomfort; palpitations;
dyspnea; orthopnea; PND; edema
Patient denies
G/I
Appetite Δ; jaundice; nausea/emesis;
dysphagia; heartburn; pain;
belching/flatulence; Δ in bowel habits;
hematochezia; melena; hemorrhoids;
constipation; diarrhea; food
intolerance
Patient denies
Urinary
Frequency; nocturia; urgency; dysuria;
hematuria; incontinence
MALES
: caliber of urinary stream;
hesitancy; dribbling
Patient denies
G/U
(General)
Sexual habits; interest; function;
