Use the HEENT write history and physical assessment template to document your write-up. One thing to pay attention to with the write-up is the difference between the ROS and the PE. Many students get these confused and end up missing a significant amount of points. Remember the ROS subjective; it is what the patient tells you. This will be documented as ‘denies’. i.e. “Denies change in hearing”. The PE is the objective information. It is what you see during your physical exam. Also, avoid using the term ‘normal’. There is almost always a more descriptive way to report your physical findings.
Northern Kentucky University
MSN 610: Diagnostic Reasoning and Advanced Physical Assessment
Comprehensive History & Physical Exam
DEMOGRAPHICS
Providers Name: ____________Patient’s Initials: (Data Source)___________
Date of Exam: _______________Patient’s DOB/AGE: _______________
Chief Complaint: ___________Gender/Sexual Orientation: _____________
History of Present Illness:
Past Medical History:
Active Problems:
Resolved Problems:
Previous Hospitalizations:
Surgical History:
Allergies:
Current Medications:
Social History:
Living Arrangements:
Occupation:
Environmental Safety:
Smoking:
Alcohol:
Drugs:
Diet:
Other Non-Prescribed Drugs:
Family History:
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Preventative Health/ Anticipatory Guidance: (Age Appropriate)
- Safety Issues:
- Screenings:
- Immunizations:
Reproductive health:
Review of Systems:
General:
Skin, Hair, Nails:
HEENT:
Neck:
Cardiovascular:
Pulmonary:
Abd/GI:
Genitourinary/ Gynecology/ Breast:
Musculoskeletal:
Neuro:
Endo/Lymphatic:
Hematology:
Psych:
Physical Exam
Vital Signs: Temp: __________ Pulse: _______ BP: _________/________ Resp: ______ O2 sat: _________
| General:
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| Head:
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| Ears:
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| Eyes:
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| Nose:
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| Throat:
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| Neck:
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Assessment Statement:
Problem List (As many or as few as needed)
Include ICD – 10 CODE
1.
2.
3.
Plan:
1.
2.
3.
4.
Submitted by: __________________________________________________
Date: __________________________________________
| Criteria | Ratings | Pts | ||
| Provider’s Name |
|
1 pts | ||
| Patient’s Initials |
|
1 pts | ||
| Date of Exam |
|
1 pts | ||
| Patient’s DOB & Age |
|
2 pts | ||
| Patient’s Gender & Sexual Orientation |
|
2 pts | ||
| Chief Complaint |
|
1 pts | ||
| HPI (onset, symptoms–location, quality, quantity, timing; setting, aggravating or alleviating factors, associated problems or symptoms) |
|
5 pts | ||
| PMH: hildhood diseases, adult diseases/medical conditions, accidents/injury history, immunization history |
|
5 pts | ||
| Allergies (drugs, IV contrast, bandages, pollen, plants, food, animal, occupational) |
|
3 pts | ||
| Current medications |
|
5 pts | ||
| Social History (smoking or tobacco use, ETOH, caffeine, substance abuse, education attained, occupation, marital status, children?, lifestyle/activity level, diet, sports/activities/leisure/hobbies) |
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10 pts | ||
| Family History: Parents, siblings, children, grandparents (include ages, chronic medical conditions, malignancies, hereditary diseases, causes of death and age at death if applicable, suicide?) |
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5 pts | ||
| Reproductive & Sexual Health: First day of LNMP if applicable, date of first menarche if applicable, GPTPAL (if applicable), Libido issues?, STI history, contraception? |
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5 pts | ||
| Review of Systems (ROS): General: weight gain/loss, appetite changes, sleeping habits, fever, fatigue, weakness, general health |
|
5 pts | ||
| ROS: Skin: color changes, rashes, sores, pain, pruritis, hemorrhages, hair loss/pattern, changes in nails |
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5 pts | ||
| ROS: HEENT: headache, migraine, vision changes, cataracts, diplopia, otalgia, otorrhea, hearing changes, rhinorrhea, epistaxis, sinus drainage/pain, sore throat, hoarseness, dental pain/missing teeth, jaw pain or clicking |
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10 pts | ||
| ROS: Breasts: discharge, pain, enlargement, lesions, galactorrhea |
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5 pts | ||
| ROS: Respiratory: Pleuritic pain, tachypnea, asthma/wheezing, bronchitis, COPD/SOB/wheezing, TB history/treatment, orthopnea, DOE, sputum production, hemoptysis |
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10 pts | ||
| ROS: CV: chest pain, palpitations, pedal edema, cyanosis, claudication, phlebitis, hypertension, orthostatic hypotension, dizziness |
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10 pts | ||
| ROS: GI: nausea, vomiting, diarrhea, anorexia, dysphagia, hematemesis, bloating, flatulence, abdominal pain, constipation, clay-colored stools, hemorrhoids, hematochezia, melena, jaundice, GERD/heartburn |
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10 pts | ||
| ROS: GU: urinary frequency, dysuria, nocturia, flank pain, hematuria, penile discharge/vaginal discharge, incontinence (and details of same if positive), urinary retention, UTI hx, STI hx, fertility/contraception/orgasms issues or treatment hx |
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10 pts | ||
| ROS: MS: muscle pain, joint pain, loss of function, decreased ROM, loss of strength, joint swelling, hx of fractures/dislocations, hx of trauma/surgeries, back pain |
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10 pts | ||
| ROS: Neuro: dizziness, headache, sleep changes, syncope/near-syncope, paralysis, paresthesia, hx of LOC, hx of seizures, hx of loss of bowel or bladder control, loss of memory |
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10 pts | ||
| ROS: Endocrine: polyphagia/uria, goiter, lethargy, hot/cold intolerance, nervousness, obesity, change in sex characteristics, amenorrhea, gynecomastia, flushing |
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10 pts | ||
| ROS: Psychiatric: anxiety, depression, hallucinations (specify if positive whether auditory, visual, gustatory, olfactory, command), suicidal ideation, hx of suicide attempt, hx of involuntary commitment, homicidal ideation, delusions |
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10 pts | ||
| Physical Exam: VS (temp, HR, BP, RR, O2 sat) |
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5 pts | ||
| Physical Exam: General: must be at least 3 items |
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5 pts | ||
| Physical Exam: Head: skull, scalp, face–shape, size, profile, symmetry, pain, meningeal signs? |
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5 pts | ||
| Physical Exam: Ears: Shape/symmetry of auricles, canals, TM, auditory testing (Weber, Rinne, whisper) |
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5 pts | ||
| Physical Exam: Eyes: visual acuity, visual fields, symmetry, drainage, eye position and alignment, PERRLA?, EOMI?, ophthalmoloscopy (red reflex, optic disc, vessels, papilledema, hemorrhages, retinopathy?) |
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5 pts | ||
| Physical Exam: Nose: external and internal, patent nares? drainage? sinus pain? turbinates? bleeding? olfacation? |
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5 pts | ||
| Physical Exam: Throat/mouth: jaw motion, lips, salivary glands, cheeks, tongue, teeth, gums, oral mucosa, pharynx, tonsils, uvula, soft/hard palate |
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5 pts | ||
| Physical exam: Neck: flexibility, shape, symmetry, goiter/thyroid, lymph nodes and name, trachea, auscultate carotids, JVD? |
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5 pts | ||
| Assessment Statement: including at least 3 problems or education deficits
Remember, this is where you discuss your findings both from the history and the physical exam, this is where you put your medical decision making–either why an intervention is needed or why there isn’t an intervention needed, it’s your “wrap up” as if you are talking to another medical provider. |
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15 pts | ||
| PLAN: at least 3 steps to address the problem list
write here next to at least 3 problems what you would do to address these, recommend to the patient, educate the patient, refer out to specialist, run tests, prescribe medication, etc. You don’t have to do all of these, but you have to write next to each problem what you would do |
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15 pts | ||
| Your signature and date
You have to sign every chart or documentation you do as a provider, and you have to write the date you sign it. |
|
5 pts | ||
| Total Points: 226 | ||||