History Taking form.pdf
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A medical history report should include: (1) details of the patient's chief complaint including age, sex, symptoms and onset; (2) past medical, family and social histories; (3) a review of symptoms addressing multiple body systems. The chief complaint section characterizes symptoms in terms of seven attributes and whether other symptoms are denied.
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Edyth T. James Department of Nursing Daily Clinical Log Cl
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Daily Clinical Log
Client Name: _____________________________
Client’s Age: _________ Gender: ________________
Present Medical Diagnoses: ____________________________________________________________________________
Present Surgery (if applicable): _____________________
Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):
__________________________________________________________________________________________________________________________________________________________________
Spiritual Well-Being: _________________________________________________________________________________
Allergies: __________________________ Code Status: _________________________
Vital Signs: T_____________ P_____________ R____________ BP______________ SPO2__________
Physical Examination:
General Appearance:
Psychiatric:
HEENT:
Neck and Lymph Nodes:
Pulmonary:
Cardiovascular:
Skin and Nails:
Abdomen:
Genitourinary:
Pelvic and Rectal:
Extremities:
Musculoskeletal:
Neurological (DTR’s, reflex grading, cranial nerve evaluation):
Incisions:
Drains:
Diet/Nutrition:
IVs:
Intake and Output:
Fall Risk Assessment (include score): Pressure Ulcer Risk Assessment (include score):
Pain assessment (include reassessment):
Time
Score
Intervention
Reassessment Time
Score
Diagnostic Assessments – Important EKGs, X-Rays, and Labs:
Lab/Other Test
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Medications Ordered for Client:
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Dose with Brand name
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Nursing Diagnoses
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Nursing Interventions
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Instructor: ______________________________ Clinical Course: ______________________
Client’s Initials: ___________ Age: _________ Sex: ________ Room#: ________________
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Present Medical Diagnoses: ____________________________________________________
Present Surgery (if applicable): _____________________ Date of Surgery: ______________
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Code Status: ________________________
Section I
General Data
(Points 5)
Chief Complaint:
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Social History:
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Immunization History:
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This document provides an overview of the health assessment process, including the purpose, components, and guidelines for taking a patient's health history. The main points are:
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The document provides information on assessing a patient's health through history taking and physical examination. It discusses the importance of the nurse's role in assessment and outlines the key components of assessment, including taking the patient's health history, performing a physical examination of various body systems, nutritional assessment, and related diagnostic tests. It emphasizes the process of comprehensive history taking, including chief complaint, history of present illness, past medical history, and use of tools like the family tree. It also covers principles and techniques for performing a respectful physical examination.
Week 4 Genitourinary Clinical Case © 2016 So.docx
Week 4: Genitourinary Clinical Case
© 2016 South University
2
Week 4: Genitourinary Clinical Case
Patient Setting:
28-year-old female presents to the clinic with a 2 day history of frequency, burning and pain upon
urination; increased lower abdominal pain and vaginal discharge over the past week.
HPI
Complains of urinary symptoms similar to those of previous urinary tract infections (UTIs) which started
approximately 2 days ago; also experiencing severe lower abdominal pain and noted brown fouls
smelling discharge after having unprotected intercourse with her former boyfriend.
PMH
Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1; Gravida IV Para III
Past Surgical History
Tubal ligation 2 years ago.
Family/Social History
Family: Single; history of multiple male sexual partners; currently lives with new boyfriend and 3
children.
Social: Denies smoking, alcohol and drug use.
Medication History
None
Trimethoprim (TOM)/ Sulfamethoxazole (SMX) rash
NKDA
ROS
Last pap 6 months ago, Denies breast discharge. Positive for Urine looking dark.
Physical exam
BP 100/80,
HR 80,
RR 16,
T 99.7 F,
Wt 120,
Ht 5’ 0”
Gen: Female in moderate distress.
HEENT: WNL.
Cardio: Regular rate and rhythm normal S1 and S2.
Chest: WNL.
Abd: soft, tender, increased suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage.
Rectal: WNL.
Page 2 of 3
Advanced Nursing Practice I
©2016 South University
3
Week 4: Genitourinary Clinical Case
EXT: WNL.
NEURO: WNL.
Laboratory and Diagnostic Testing
Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2%
UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many, Lkcs 10-
15, RBC 0-1
Urine gram stain – Gram negative rods
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Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative
Page 3 of 3
Advanced Nursing Practice I
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3. A request for x-rays and notes on any complicating factors.
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This medical evaluation form collects information about a patient's medical history, presenting complaints, past medical history, drug and treatment history, family history, and physical exam findings. The physical exam includes a general exam noting vital signs and appearance, as well as detailed exams of the head, neck, chest, abdomen, extremities, and neurological system. The form is used to document a comprehensive medical evaluation.
Edyth T. James Department of Nursing Daily Clinical Log Cl
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Client Name: _____________________________
Client’s Age: _________ Gender: ________________
Present Medical Diagnoses: ____________________________________________________________________________
Present Surgery (if applicable): _____________________
Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):
__________________________________________________________________________________________________________________________________________________________________
Spiritual Well-Being: _________________________________________________________________________________
Allergies: __________________________ Code Status: _________________________
Vital Signs: T_____________ P_____________ R____________ BP______________ SPO2__________
Physical Examination:
General Appearance:
Psychiatric:
HEENT:
Neck and Lymph Nodes:
Pulmonary:
Cardiovascular:
Skin and Nails:
Abdomen:
Genitourinary:
Pelvic and Rectal:
Extremities:
Musculoskeletal:
Neurological (DTR’s, reflex grading, cranial nerve evaluation):
Incisions:
Drains:
Diet/Nutrition:
IVs:
Intake and Output:
Fall Risk Assessment (include score): Pressure Ulcer Risk Assessment (include score):
Pain assessment (include reassessment):
Time
Score
Intervention
Reassessment Time
Score
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Patient values
Inference
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Student: _________________________________ Date: ______________________________
Instructor: ______________________________ Clinical Course: ______________________
Client’s Initials: ___________ Age: _________ Sex: ________ Room#: ________________
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Present Surgery (if applicable): _____________________ Date of Surgery: ______________
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General Data
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Social History:
Family History of Illness:
Immunization History:
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Health assessment
This document provides an overview of the health assessment process, including the purpose, components, and guidelines for taking a patient's health history. The main points are:
- The purpose of a health assessment is to collect physical, mental, and social data about a client to identify problems, make clinical decisions, and evaluate outcomes of care.
- Taking a health history is a key part of the assessment process and involves systematically gathering both subjective data from the client and objective data observed by the nurse.
- There are several components that should be covered during a health history, including biographical data, chief complaints, history of present illness, past medical history, and family, social, and occupational information.
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Health assessment of Patient ppt
The document provides information on assessing a patient's health through history taking and physical examination. It discusses the importance of the nurse's role in assessment and outlines the key components of assessment, including taking the patient's health history, performing a physical examination of various body systems, nutritional assessment, and related diagnostic tests. It emphasizes the process of comprehensive history taking, including chief complaint, history of present illness, past medical history, and use of tools like the family tree. It also covers principles and techniques for performing a respectful physical examination.
Week 4 Genitourinary Clinical Case © 2016 So.docx
Week 4: Genitourinary Clinical Case
© 2016 South University
2
Week 4: Genitourinary Clinical Case
Patient Setting:
28-year-old female presents to the clinic with a 2 day history of frequency, burning and pain upon
urination; increased lower abdominal pain and vaginal discharge over the past week.
HPI
Complains of urinary symptoms similar to those of previous urinary tract infections (UTIs) which started
approximately 2 days ago; also experiencing severe lower abdominal pain and noted brown fouls
smelling discharge after having unprotected intercourse with her former boyfriend.
PMH
Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1; Gravida IV Para III
Past Surgical History
Tubal ligation 2 years ago.
Family/Social History
Family: Single; history of multiple male sexual partners; currently lives with new boyfriend and 3
children.
Social: Denies smoking, alcohol and drug use.
Medication History
None
Trimethoprim (TOM)/ Sulfamethoxazole (SMX) rash
NKDA
ROS
Last pap 6 months ago, Denies breast discharge. Positive for Urine looking dark.
Physical exam
BP 100/80,
HR 80,
RR 16,
T 99.7 F,
Wt 120,
Ht 5’ 0”
Gen: Female in moderate distress.
HEENT: WNL.
Cardio: Regular rate and rhythm normal S1 and S2.
Chest: WNL.
Abd: soft, tender, increased suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage.
Rectal: WNL.
Page 2 of 3
Advanced Nursing Practice I
©2016 South University
3
Week 4: Genitourinary Clinical Case
EXT: WNL.
NEURO: WNL.
Laboratory and Diagnostic Testing
Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2%
UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many, Lkcs 10-
15, RBC 0-1
Urine gram stain – Gram negative rods
Vaginal discharge culture: Gram negative diplococci, Neisseria gonorrhoeae, sensitivities pending
Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative
Page 3 of 3
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©2016 South University
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To achieve optimum results from job ads, four elements model is used in order to maximize candidates’ attention, interest, desire, and action (AIDA).
Attention: The ads that stand out have borders, company logo, and effective design.
Interest: Interest can be created by the nature of the job itself, by pointing out the range of duties and the amount of challenge or responsibility involved. To ensure attracting qualified applicants, the job specification should always be included.
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This document outlines Gordon's functional health patterns approach to nursing assessment. It includes 11 sections that assess various health patterns including nutritional status, elimination, activity, sleep, and relationships. Each section lists relevant questions and data to collect. The assessment is meant to gather a holistic understanding of the patient's health across multiple domains to inform nursing diagnoses and the care plan.
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This pediatric physical assessment form documents a patient's admission information, vital signs, developmental stage, physical exam findings, labs, diagnostic tests, discharge planning, nursing diagnoses, medications, impact of hospitalization, appropriate play therapy, and safety considerations. The patient's presenting signs and symptoms, height, weight, heart rate, respiratory rate, blood pressure, and temperature are recorded along with any allergies, pain scale, diet, IV fluids, and weight changes. A full physical exam including integumentary, neurological, respiratory, cardiovascular, musculoskeletal, and gastrointestinal systems is documented.
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**Please delete the instructions in each section prior to submitting the assignment
Student Name: Date: Course:
Subjective:
Patient Demographics: (age, gender, gender identity, ethnicity, etc.)
Chief Complaint: “quote patient”
History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)
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PSH: surgery dates in reverse chronological order.
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Search reputable local and national media for a man-made disaster to discuss.
Search for critical instances such as: hostage situations, mass shootings, multiple-vehicle or mass transit accidents with multiple critical injuries, and disease outbreaks.
In your initial post, describe the incident and address the following:
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Patient SOAP Note Charting Procedures
S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.
Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.
Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.
Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.
SOAP NOTE TEMPLATE
**Please delete the instructions in each section prior to submitting the assignment
Student Name: Date: Course:
Subjective:
Patient Demographics: (age, gender, gender identity, ethnicity, etc.)
Chief Complaint: “quote patient”
History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)
PMH: dates in reverse chronological order.
PSH: surgery dates in reverse chronological order.
Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies
Untoward Medication Reactions: include type ...
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- 1. Your medical history taking report must include the following information: History of Present Illness ______ Y/O ___________ who reports _________________________________________ for (age) (sex) (chief complaint) _______________________. (onset) Principal symptom should be characterized in terms of the seven (7) attributes: 1. Location 2. Quality 3. Quality or severity 4. Timing (duration and frequency) 5. Setting 6. Factors that have aggravated or relieved the symptom 7. Associated manifestation/positive pertinents Patient denies __________________________________ (negative pertinents) Past Medical History Childhood illness: Adult illness: Surgeries: Medications: Allergies: Obstetric/Gynecologic: (obstetric history, menstrual history) Blood transfusions: Hospitalizations: Trauma/Falls: Immunizations: Health maintenance: Family History Father: Mother: Others:
- 2. Social History Occupation/Job History: Education: Marital Status: Hobbies/Personal Interests: Living with: Finances: Religion/Spirituality: Diet: Exercise: Sexual History: Toxic habits: tobacco, drugs, alcohol use Review of Systems General Skin HEENT Neck Breasts Respiratory Cardiovascular Gastrointestinal Urinary Genital Peripheral vascular Musculoskeletal Psychiatric Neurologic Hematologic Endocrine