D117 Advanced Health Assessment Documentation Form

D117 Advanced Health Assessment Documentation Form

Student Name

Western Governors University

D117 Advanced Health Assessment for the Advanced Practice Nurse

Prof. Name:

Date

D117 Advanced Health Assessment Documentation Form

Patient Demographics and Vital Signs

What are the key demographic details and vital signs to be documented?

Patient demographics include initials, height, weight, age, sex assigned at birth, gender identity, and race/ethnicity. Additional information such as marital status, preferred pronouns, body mass index (BMI), and temperature is essential. Vital signs to record include respiratory rate, heart rate, and blood pressure.

Chief Complaint and History of Present Illness (HPI)

What is the patient’s main concern and current illness history?

The chief complaint captures the primary reason for the patient’s visit. The history of present illness (HPI) provides a detailed, focused description of the orthopedic or other medical issues, including onset, duration, severity, and associated symptoms.

Medications and Allergies

Which medications and allergies should be documented?

List all current medications, including the name, dosage, directions, and indication for use. Allergies should be recorded with details on the specific allergen and the reaction experienced.

Allergies and Reactions:
Specify all known allergies and the nature of reactions.

Past Medical History (PMH)

What elements should be included in past medical history?

Include any relevant past illnesses, hospitalizations, chronic conditions, and surgeries with dates. Vaccination history should also be documented, including dates for flu, pneumococcal, and tetanus vaccines.

Family History

How should family history be recorded?

Document any significant diseases within the family, specifying the affected relative (mother, father, siblings, maternal/paternal grandparents) and noting whether they are alive or the age at death.

Personal and Social History

What social and personal factors affect health?

Social history includes tobacco and alcohol use, substance abuse, exercise habits, safety practices (e.g., seatbelt and helmet use), education level, literacy, language, occupation, financial concerns, and support systems. Additional factors include transportation access, communication means (phone/internet), religion and related health considerations, hobbies, and sexual history.

Review of Systems (ROS)

How is the review of systems conducted and documented?

ROS involves screening multiple body systems for symptoms or signs. Each system is checked for negative or positive findings. Positive findings are further described with detailed attributes from the HPI or PMH.

Physical Examination

What observations and system examinations are important during physical assessment?

A comprehensive physical exam assesses general appearance, head and face, eyes, ears, nose, mouth, throat, neck, thorax (anterior, posterior, lateral), cardiovascular, abdomen, neurological, and musculoskeletal systems. Additional endocrine and psychiatric evaluations are included.

General Observations:

• Appearance (well or ill-appearing)

• Level of consciousness

• Nutritional status and body habitus

• Deformities or mobility issues

• Mood and affect

• Speech and hygiene

Neurological Examination Includes:

• Cranial nerve testing (I through XII)

• Coordination and sensory testing

• Reflexes (deep tendon)

• Meningeal signs

Focused Orthopedic Examination

How are specific orthopedic tests documented?

The orthopedic assessment involves a series of specific tests depending on the region examined. Examples include:

References

(Adapted and rephrased from Advanced Health Assessment Documentation Form. CourseHero.com. Retrieved December 20, 2025, from https://www.coursehero.com/file/229774868/Advanced-Health-Assessment-Documentation-Formpdf/)