Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:___4-27-20 _______ Patient Information Patient Initials R.O. Age 50 yrs. old Sex male Chief Complaint “Here for a Comprehensive Health Assessment” History of Present Illness (HPI) No specific patient complaints 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Prescription none Over the Counter Prilosec OTC – 1 tablet per day Allergies No known drug or environmental allergies Medical HX (PMH) Childhood Denies childhood illnesses Adult Denies any illness or medical problems. Patient does take OTC medication daily for gastric reflux Surgical B Lasix Eye surgery-1997 & Vasectomy-2004 Ob/Gyn Not applicable – Patient is male Psychiatric Denies psychiatric history Vaccinations Flu Date: denies Pneumovax Date: denies Tetanus Date: >7-10 years ago Family HX (specify family member affected/age at death) 1
Father deceased at age 70-heart failure Mother – living with HTN Brother – living with HTN Sister deceased at age 40-Breast Cancer with bone metastasis Social/Environmental HX HTN DM Ca MI/CAD CVA TB Denies all above Renal dz Thyroid dz Suicide *Alcoholism *Substance abuse Denies renal disease, thyroid disease, suicidal thoughts or attempts. *Patient states averages 3-7 alcohol drinks per week. *Patient states smoked for a total of 5 years 25 years ago, but denies substance abuse Born in: Huntsville, Alabama in 1970 Education: High School Graduate Occupation: Appliance Salesman Family situation: Married, 2 children Transportation options: Patient has private vehicle, but drives company vehicle to work Insurance: has medical/dental insurance, also confirms home/car insurance coverage Neighborhood: Patient is a land & home owner in suburb county area. Language/Literacy: English speaking, average literacy Access to emerging technologies: yes, patient if familiar with and uses technology daily Interests/Hobbies: Hunting and Fishing 2
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?
You've reached the end of your free preview.
Want to read all 11 pages?
- Spring '16
- Shelley Ashby
- involuntary movements, lower extremities