Documenting Comprehensive Assessment

Question 1

At end of documentation/Nurse forms a problem list

Answer 1

Problem list provides basis for determining plan of care, including educational needs of the patient

Question 2

Health History

Answer 2

Biographic data
Reason for seeking care
H
History of present illness
Present health status
Past health status
Family history
Personal & Psychosocial h/x
Review of systems
Physical exam
Problem list

Question 3

Present Health H/X

Answer 3

Chronic illness?
Medications?
Allergies?

Question 4

Personal/Psychosocial H/X

Answer 4

Personal Status
Family/Social relationships
Diet/Nutrition
Functional ability
Mental Health
Tobacco/Alcohol/Illicit drug use
Health Promotion Activities
Environment

Question 5

Past Health H/X

Answer 5

Childhood illness
Surgeries/hospitalizations
Accidents/injuries
Immunizations
Last examinations
Dental
Mammogram

Question 6

Diet/Nutrition

Answer 6

Describe appetite
Breakfast
Lunch
Dinner
Fluids

Question 7

Review of Systems

Answer 7

General Symptoms
Skin/Hair/Nails(Health promotion)
Head/Eyes/Ears/Nose/Throat (Health promotion)
Breast (Health Promotion)
Respiratory System
Gastrointestinal System (daily BM)
Urinary System (describe urine)
Musculoskeletal System
Neurologic System (cognitive function/coordination/sensory)
Reproductive System

Question 8

Physical Exam

Answer 8

General Survey(V/S/Ht/Wt/BMI/orientation/appearance)
Skin/Hair/Nails
Head (skull symmetry/scalp/face/jaw/temporal arteries)
Eyes(vision/peripheral vision/ophthalmic exam)
Ears
Nose
Mouth(temporomandibular joint/lips/mucous membranes/head/soft & hard palates/uvula/pharynx/tonsils)
Neck (trachea/thyroid/neck rom/lymph nodes)
Chest & Lungs (Breathing/AP/thorax/muscle development of thorax/thoracic expansion/tactile fremitus/spinous process/scapula/lungs)
Brest (size/granular consistency/axillary lymph nodes)
Heart (apical pulse/carotid/rate/rhythm)
Peripheral Vascular (distal pulses/jugular distention/lower ext/hair distribution/edema/turgor/capillary refill/nail beds/thigh circumference)
Abdomen (Inspection/quadrants/palpation/umbilical/tympany tones/midclavicular line/liver/gallbladder/spleen/kidney)
Musculoskeletal (ROM/vertebral column/gait)
Neurologic (oriented/cranial nerves 1-XII/peripheral sensations/gait/movement/deep tendon reflexes)
Genitalia (pubic hair/labia/urethras meatus/perineum/anus)