NUR2180 Comprehension patient history. Comprehensive History and Patient Examination
Patient Name: ______________________________________________________________________ Age: ________ Sex: __________ Race: _________
Subjective Data Collection: Describe client chief complaint (C/C) in narrative format.
Past Medical History:
Allergies:
Medications:
Medical:
Surgical:
Health Maintenance: Last physical:
Immunizations and Date if known:
Recent travel or Military service:
Family Health History:
Psychiatric Health History:
Nutritional Health History:
Personal Habits: {Sleep patterns, health practices, Tobacco, Alcohol, Drugs, cultural/religious influences}
Review of systems:
Eyes:
Head, ears, nose, mouth, throat, neck:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary:
Neurological:
Endocrine:
Hematologic/Lymphatic:
Immunological:
Female/Male Reproductive Organs: {Breast, Scrotal, Rectal, Vaginal}
Physical Assessment: Objective Data collection
LOC: ______________________, Appearance: ________________________ Speech: _______________
Vital Signs: Blood Pressure: ___________, RR: _____________, HR: _____________,Temperature: _________, Height and Weight:___________________________
Clinical Findings: Describe patient assessment in narrative format.
Skin, Hair, Nails:
(Head, eyes, ears, nose, mouth, throat, neck, lymph) HEENT:
Respiratory system:
Cardiovascular system:
Gastrointestinal system:
Genitourinary:
Musculoskeletal system:
Neurological system (Document findings on CN I-VII):
Functional Assessment:
ASSESSMENT: (Top 5 assessment findings that have actual or potential risk factors).
1. ___________________________________________________________________________________
2.___________________________________________________________________________________ 3.___________________________________________________________________________________ 4.___________________________________________________________________________________5.___________________________________________________________________________________
Completed by: ________________________________________________________________________
Comprehensive Patient History and Examination
A comprehensive patient history and examination is crucial for nurses to properly assess, diagnose and develop a treatment plan for patients. Let me address the key components you outlined for a thorough history and examination.
Chief Complaint and Subjective Data Collection
The chief complaint, or reason for the visit, should be documented in the patient’s own words to gain their perspective on the issue (Williamson & McCutcheon, 2018). This subjective data from the patient provides valuable contextual insight.
Past Medical, Surgical, Family and Social Histories
Thorough documentation of past and current medical issues, surgeries, family health trends, and social/lifestyle factors is important for understanding the patient holistically. This could reveal underlying conditions or risk factors relevant to their chief complaint (Kennedy et al., 2019).
Review of Systems
A systems-based review of symptoms allows the nurse to efficiently screen multiple body systems for other potential problems. This identifies red flags and guides focused assessment (Jarvis, 2016).
Objective Physical Examination
Documenting objective physical findings through visual inspection, auscultation, palpation and other examination techniques provides measurable clinical data to corroborate or refute the subjective report (Peate, 2016).
Assessment
The assessment summarizes and analyzes the most pertinent findings to form a nursing diagnosis and guide the plan of care. Prioritizing the top 5 issues establishes an actionable focus (Ignatavicius & Workman, 2020).
Thorough documentation demonstrates comprehensive care, facilitates communication between providers, and establishes a baseline for monitoring changes over time. I hope this overview helps explain the value and components of a high-quality history and physical assessment. Please let me know if you need any clarification or have additional questions.
Williamson, G. R., & McCutcheon, H. (2018). Clinical skills for OSCEs. Elsevier Health Sciences.
Kennedy, R. L., Brown, C., & Dannaway, R. (2019). Advanced health assessment and clinical diagnosis in primary care. McGraw Hill Professional.
Jarvis, C. (2016). Physical examination and health assessment. Elsevier Health Sciences.
Peate, I. (Ed.). (2016). Fundamentals of anatomy and physiology for nursing and healthcare students. John Wiley & Sons.
Ignatavicius, D. D., & Workman, M. L. (2020). Medical-surgical nursing: Patient-centered collaborative care. Elsevier Health Sciences.
