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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate:___4-27-20_______Patient InformationPatient InitialsR.O.Age50 yrs. oldSexmaleChief Complaint“Here for a Comprehensive Health Assessment”History of Present Illness (HPI)No specific patient complaints7 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsPrescriptionnoneOver the CounterPrilosec OTC – 1 tablet per dayAllergiesNo known drug or environmental allergiesMedical HX (PMH)ChildhoodDenies childhood illnessesAdultDenies any illness or medical problems. Patient does take OTC medication daily for gastric refluxSurgicalB Lasix Eye surgery-1997 & Vasectomy-2004 Ob/GynNot applicable – Patient is malePsychiatricDenies psychiatric historyVaccinationsFluDate: deniesPneumovaxDate: deniesTetanusDate: >7-10 years agoFamily HX (specify family member affected/age at death)1
Father deceased at age 70-heart failure Mother – living with HTNBrother – living with HTNSister deceased at age 40-Breast Cancer with bone metastasisSocial/Environmental HXHTNDMCaMI/CADCVATBDenies all aboveRenal dzThyroid dzSuicide*Alcoholism*Substance abuseDenies renal disease, thyroid disease, suicidal thoughts or attempts. *Patient states averages3-7 alcohol drinks per week.*Patient states smoked for a total of 5 years 25 years ago, but denies substance abuseBorn in: Huntsville, Alabama in 1970Education: High School GraduateOccupation: Appliance SalesmanFamily situation: Married, 2 childrenTransportation options: Patient has private vehicle, but drives company vehicle to workInsurance: has medical/dental insurance, also confirms home/car insurance coverageNeighborhood: Patient is a land & home owner in suburb county area. Language/Literacy: English speaking, average literacyAccess to emerging technologies: yes, patient if familiar with and uses technology dailyInterests/Hobbies: Hunting and Fishing2
Interview Questions for Social Determinants: Economic Stability: Can you tell me about your job?How far do you have to travel for your job?Can you tell me where you live? Do you own your house? Do you have a mortgage & insurance on your home? Are you able to make those payments appropriately and on time?Education:What is your highest level of education? Social & Community Context:Tell me about your support system. Who are they? Are you able to spend time with family & friends?Do you live in a rural or urban community? Do you have access to community resources?Health & Healthcare: Do you have a primary care physician (or access to one)? When was your last physical?Where do you go for urgent or emergency care?