docx (3).docx - Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date Patient Information Patient Initials

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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:__12/23/18________ Patient Information Patient Initials CM Age 20 Sex M Chief Complaint Physical assessment History of Present Illness (HPI) No illness at this time 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications none Allergies none Medical HX (PMH) 1
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Childhood none Adult none Surgical none Ob/Gyn none Psychiatric none Vaccinations Flu Date: 10/13/18 Pneumovax Date: unknown Tetanus Date: unknown Family HX (specify family member affected/age at death) none Social/Environmental HX HTN DM Ca MI/CAD CVA TB Renal dz Thyroid dz Suicide Alcoholism Substance abuse Born in: Florida Education: High School and Firefighter/EMT school Occupation: Firefighter/EMT Family situation: single Transportation options: owns vehicle Insurance: yes Neighborhood: good Language/Literacy: English Access to emerging technologies: going back to school for fire certifications. Interests/Hobbies: works out, hunts 2
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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 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 Last BM 12/23/18 Urinary Frequency; nocturia; urgency; dysuria; negative 3
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hematuria; incontinence MALES : caliber of urinary stream; hesitancy; dribbling G/U (General) Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposure negative Male G/U Discharge from or sores on penis; testicular pain/masses negative 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; negative Peripheral Vascular Claudication; leg cramps; varicose veins; hx of blood clots negative Musculo- skeletal Muscle or joint pain; joint stiffness negative Neuro Syncope; seizures; weakness; paralysis; numbness/tingling; tremors;
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  • Spring '16
  • Shelley Ashby
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