Our Nursing Papers Samples/Examples

Comprehensive Women's H & P Template

Comprehensive Women’s Health History and Physical Template

Encounter date: 

Patient Initials: Gender: Age: Race/Ethnicity: 

Reason for Seeking Health Care

History of Present Illness (HPI)

Allergies (Drug/Food/Latex/Environmental/Herbal)

Current Perception of Health 

Current Medications (including over the counter) 

Menstrual History

Age at Menarche

Last menstrual period

Menstrual Pattern

Cycle Length

Duration of Flow

Amount of Flow 

Bleeding Pattern

Break through Bleeding

Gynecologic History

History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable)

Previous GYN surgery (may include that in surgical history)

History of infertility

History of diethylstilbestrol (DES) use by patient’s mother

Last pap smear, history of abnormal pap

Pre-menopause/menopause

Vasomotor symptoms

Hormone Replacement Therapy

Sexual and Contraceptive History

Current method of contraception

Sexually active

Number of sexual partners

New partners in the 3-6 months

Condom use 

History of sexual abuse

History of sexually transmitted infections (STIs)

Obstetric History (including complications)

Past Medical History (PMH)

Major/Chronic Illnesses

Trauma/Injury

Hospitalizations

Past Surgical History

Family Medical History

Social History

Living condition

Marital status

Education

Employment

Occupation

Social supports

Habits (smoking, alcohol use and illicit drugs use)

Health Maintenance 

Age-appropriate health promotion/maintenance and screening history

Immunization history

Review of Systems (ROS)

General 

Dermatology

HEENT

Neck

Pulmonary System

Cardiovascular System (CVS)

Breast

Gastrointestinal (GI) System 

Genitourinary (GU) System

Female Genitalia

Musculoskeletal System 

Neurological System.

Endocrine

Psychologic

Hematologic/Lymphatic

Physical Examination

Vital Signs

Blood Pressure (BP: Temperature Heart Rate (HR) Respiratory Rate (RR)

Height Weight Body Mass Index (BMI) Pain 

General Appearance

Dermatology

HEENT

Neck

Pulmonary System

Cardiovascular System (CVS)

Breast

Gastrointestinal (GI) System 

Genitourinary (GU) System

Female Genitalia

Musculoskeletal System 

Neurological System.

Endocrine

Psychologic

Hematologic/Lymphatic

Significant Data/Contributing Dx/Labs/Misc





Assessment

Differential Diagnoses (3 minimum)

Primary Diagnoses

Plan (For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit)

Diagnoses

Laboratory/Diagnostic Studies

Therapeutic (Non-pharmacological interventions)

Pharmacological Therapy

Patient Education/Anticipatory Guidance

Referrals

Follow up

DEA#:  101010101                          STU Clinic                                   LIC# 10000000                                               

Tel: (000) 555-1234                                                                             FAX: (000) 555-12222

Patient Name: (Initials)______________________________        Age ___________

Date: _______________

RX ______________________________________

SIG: 

Dispense:  ___________                                                     Refill: _________________

       No Substitution 

Signature: ____________________________________________________________



Signature (with appropriate credentials): __________________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])

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