Comprehensive health assessment for family nurse practitioner
Type: SOAP NOTE
Subject: Primary Health Care Nursing
Subject area: Nursing
Education Level: Masters
Length: 5 pages
Referencing style: No Referencing Required
Preferred English: US English
Spacing Option: Double
Instructions: to complete this assignment, you will interview a volunteer patient and document a comprehensive health history using the guideline provided. you will not perform any kind of physical examination; all data will be subjective in nature. you will analyze the data you have collected and compile a list of health problems and risk factors. your patient should be at least 50 years old and have at least one chronic health problem. guidelines use the document provided below to gather a comprehensive health history. your document should be formatted in a manner that is consistent with a standard medical record rather than in essay form. be sure to address all points under the provided headings. the hpi should be written in a narrative format. other sections may include bulleted points or brief statements. the review of systems should follow the standard format, as illustrated in the textbook. in your final draft, be sure to remove the italicized instructions that are provided in the document.
Focus: chief complaint is “ i have been having pain and burning when urinating, i also have right flank pain”
Structure: please use the attached file it has the structure that needs to be used to complete the assignment. based on interview fill up each section
Important notes: comprehensive health history criteria ratings pts chief complaint and identifying data view longer description 5 to >4 pts meets standard • clearly and succinctly written. • all points of identifying data present. 4 to >3.5 pts almost meets standard • omission of some identifying data. • writing not clear and/or superfluous information included. 3.5 to >0 pts does not meet standard • little or no identifying data included. • chief complaint not consistent with data. / 5 pts history of present illness or health status data view longer description 15 to >13 pts full marks • clearly and succinctly written in narrative format. • flows logically. • includes either all applicable oldcarts or all elements of health and illness status (including chronic illnesses and positive findings from the ros). 13 to >11 pts almost meets standards omission of no more than two aspects of oldcarts or no more than one aspect of the state of health and illness (including chronic illnesses or significant ros findings). 11 to >0 pts does not meet standard omission of more than two aspects of oldcarts or more than two aspects of the state of health and illness (including chronic illnesses or significant ros positive findings). / 15 pts past medical history (pmh), social hx (nutritional screen, etc..), medications, allergies view longer description 25 to >21 pts meets standard includes all required aspects (as on the assignment description). 21 to >17 pts almost meets standard omission of no more than two aspects. 17 to >0 pts does not meet standard omission of more than two aspects. / 25 pts family history view longer description 15 to >13 pts meets standard • three generations included. • missing information is explained. • includes ages of family members or age at time of diagnosis or death. 13 to >11 pts almost meets standard fewer than three generations included or missing information is not explained. 11 to >0 pts does not meet standard fewer than three generations included and missing information is not explained. / 15 pts review of systems view longer description 20 to >17 pts meets standard • includes all systems with pertinent positives and negatives documented properly. • contains only subjective data. 17 to >14 pts almost meets standard • omission of no more than one system • documentation relating to positives and negatives mostly proper. 14 to >0 pts does not meet standard • omission of more than one system • does not properly sum up positives and negatives. • includes objective data. / 20 pts problem and risk assessment list view longer description 15 to >13 pts meets standard • relevant health issues and risk factors identified and recorded. • assessment is holistic and includes risk factors as well as known medical diagnoses. • dates of onset/risk identification are recorded. 13 to >11 pts almost meets standard • omission of no more than two health issues. • assessment is holistic and includes risk factors as well as known medical diagnoses. • dates of onset/risk identification are recorded. 11 to >0 pts does not meet standard omission of more than two health issues or assessment is not holistic (is limited to known medical diagnoses, with no consideration of apparent risk factors). / 15 pts documentation view longer description 5 to >4 pts meets standard • organized and succinct. • logical progression of information presented. • no unnecessary verbiage. • document format is consistent with usual medical record standards. • contains only subjective data. • contains appropriate medical vocabulary. 4 to
