H & P
Clinical Documentation: Complete History and Physical Examination (H&P) Guidelines
The purpose of this assignment is to (1) assist the student in developing the skill of interviewing patients to obtain a complete history and perform a correct physical exam and (2) clearly and succinctly documenting the pertinent data in a logical, organized format in the patient health record, using appropriate nursing and medical terminology. The student will gain experience in formulating a problem list.
Directions:
Select a patient seen in your clinical setting on whom to gather a history and perform a physical exam. Document the history and the physical exam in a standard, organized format using the guidelines below. A sample comprehensive history and physical examination may be found on pages 33-35 of Sullivan (2019). Save the assignment as
LastName.FirstName_NURS7710_H&P_1. The second submission should be labeled with the number two (2).
Documentation should:
• have no errors in sentence structure, word usage, grammar, or punctuation
• be clear, well-organized and logically progressive, and
• be succinct with no unnecessary verbiage.
Correct medical terminology and approved abbreviations should be used.
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Including all of the above components of the comprehensive health history add the following:
COMPLETE PHYSICAL EXAMINATION (PE)
1. Document physical exam in the following order using a systems-heading format, not narrative format:
a. General assessment
b. Vital signs: temperature, pulse, respirations, blood pressure, height weight, body mass index (BMI)
c. Skin
d. HEENT
e. Neck
f. Thorax and Lungs
g. Breasts and Axilla
h. Cardiovascular
i. Abdomen
j. Lower Extremities
k. Musculoskeletal
l. Nervous System
m. Genitourinary or gynecological and rectal
2. Do NOT document “WNL” or within normal limits for your physical exam findings. You must describe your actual exam findings using appropriate medical terminology. Document using measurable terms.
LABORATORY OR DIAGNOSTIC STUDIES
1. Tests and results (i.e., CBC, Rapid Strep-Test, Blood Glucose, Hemoglobin, Urine Pregnancy Test, Urinalysis, etc.) Not what you ordered and is pending, but the results of the tests completed.
PROBLEM LIST/ASSESSMENT
1. After you have obtained the history and physical exam of your patient, construct a problem list that should include all active or pertinent medical problems, including those discovered on ROS, physical exam, or labs/studies.
2. List at least 3 differential diagnoses. Include rationale for ruling in or ruling out diagnoses.
3. State each final diagnosis. There may only be one.
4. If diagnosis is unknown at this time, you may use the symptom (i.e., headache, fever, shoulder pain).
5. Do not write “Rule Out ______”
6. Include a brief statement (your rationale) supporting each diagnosis. This rationale should be based on subjective and objective pertinent positive and negative findings.
7. No plan is expected in this course
PLEASE FOLLOW RUBRIC CLOSELY, PLEASE PRETEND TO BE A NURSE PRACTITIONER TO HAVE THE RIGHT VIEW, PLEASE LET ME KNOW IF YOU HAVE ANY QUESTIONS, IT IS A ROLE PLAY SCENERIO, SO TYPICALLY THIS PATIENT IS HEALTHY ASIDES FROM GERD SO DONT MAKE UP NEW PROBLEMS, NO PLAGIARISM, THANKS