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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate:_9/22/2019_____Patient InformationPatient InitialsRMAge45SexFemaleChief ComplaintPatient 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 manifestationsMedicationsPatient does not take any medications. AllergiesNKAMedical HX (PMH)ChildhoodPatient deniesAdultPatient deniesSurgicalPatient deniesOb/GynPatient denies problem, unknown if patient is in care of OB/GYN1
PsychiatricPatient denies problemsVaccinationsFluDate: 2019PneumovaxDate: 2019TetanusDate: 2019Family HX (specify family member affected/age at death)Patient denies any family HX when askedSocial/Environmental HXHTNDMCaMI/CADCVATBDenies AllRenal dzThyroid dzSuicideAlcoholismSubstance abuseDenies all Born in: unknownEducation: associates degreeOccupation:RNFamily situation: lives at home with husbandTransportation options: patient hascarInsurance: patient reports havinginsuranceNeighborhood: patient lives in rural areaLanguage/Literacy: patient speaksEnglish, college degreeAccess to emerging technologies: patient does have access to varioustechnologies due to occupationInterests/Hobbies: unknown2
Review 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; feversPatient deniesSkinRash; lumps; sores; itching; dryness; color change; Δ in hair/nailsPatient deniesHeadHeadache; head injury; dizzinessPatient deniesEyesVision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotomaPatient does wear corrective lenses and states recently had eyeexam; date unknown. Denies any changes with vision, pain, or rednessEarsHearing Δ; tinnitus; earaches; infections; dischargePatient deniesNose/SinusesColds; congestion; discharge; itching; hay fever; nosebleedsPatient deniesThroatBleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarsePatient deniesNeckLumps; swollen glands; goiter; pain; neck stiffnessPatient deniesBreastsLumps; pain; discomfort; nipple dischargePatient denies3