Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:_4/6/20_________ Patient Information Patient Initials ANG Age 25 Sex F Chief Complaint Patient has no chief complaints, however, she has not had a comprehensive physical assessment in a few years. History of Present Illness (HPI) Negative 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications NuvaRing (Vaginal ring- birth control) Allergies NKA 1
Medical HX (PMH) Childhood Negative Adult Negative Surgical Wisdom teeth removal Ob/Gyn Patient is currently having periods, uses NuvaRing as birth control. No pregnancies or miscarriages. No other significant history Psychiatric Negative Vaccinations Flu Date: Unknown Pneumovax Date: Unknown Tetanus Date: Unknown Family HX (specify family member affected/age at death) Patient states that grandparents (paternal and maternal) are both healthy and living as well as parents. No other significant family medical history. Social/Environmental HX HTN DM Ca MI/CAD CVA TB *Negative Renal dz Thyroid dz Suicide Alcoholism Substance abuse *Negative Born in: Patrick County, VA Education: Associates Degree Occupation: Framer (Hobby Lobby) Family situation: No children, engaged and lives with fiancé Transportation options: Patient has a working car Insurance: Health insurance through employer Neighborhood: Rural, patient states there is low crime. 2
Language/Literacy: Patient speaks English with appropriate literacy level Access to emerging technologies: Patient feels like she has access to surrounding “top-notch” medical facilities Interests/Hobbies: Patient enjoys crafting * Five Questions for Social Determinants 1) Do you feel safe in this area? Patient: Yes. 2) Do you feel that this area is segregated? Patient: No, not really. 3) Do you feel that there is a lot of racism in this area? Patient: Yes, probably 4) Do you feel that you have access to community resources? Patient: Yes 5) Not asked on camera, but followed up after interview: Are you satisfied with the quality of your education and access to furthering it? Patient: Yes, I am thinking about pursuing a degree in photography 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 3
Eyes Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma Patient wears glasses, mainly while at work, unaware of last eye exam 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
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- Fall '18