Posted: June 22nd, 2016

Comprehensive History and Physical Examination Assignment

Week 8 Comprehensive History and Physical Examination Assignment
Comprehensive History and Physical Examination Assignment

Value: 10 % of Total Grade
Format: Follow the template below or use one that you have created and that has been approved by your instructor. Use the Power Points and Text(s) to help guide you completing this assignment. Use the headings listed below, knowing that you will need to add more information (E.g., what are the components of the Social History?) The final document should be “chart” worthy,” which means that the documentation must be clear, thorough and demonstrate knowledge of advanced history taking and advanced physical assessment skills. In addition to content, you will be graded on organization, neatness, use of approved abbreviations only and correct punctuation.

Comprehensive History- Mandatory Components:
Identifying Data – No name, only use initials
Reason for Seeking Health Care- (chief complaint in client’s own words)
History of Present Illness – Use OLDCART only if there is a complaint. Otherwise, you may simply state that the patient presents to establish care and he/she has no health concerns.
Medications
Allergies
Past Medical History
Past Surgical History
Family History – 3 generations (may use genogram)
Social History
Sexual and Reproductive History
Health Care Maintenance (HCM)
Review of Systems