NURS 5220: MODULES 1 & 2
Comprehensive Health History and Physical Examination - ANSWERS-1.All
relevant data regarding the comprehensive health history should be recorded
2. Arrange the history in chronological order
3. Arrange the physical examination findings in a consistent order and style
Problem List - ANSWERS-1. A problem may be related to any of the following:
- A firmly established diagnosis
- A new symptom or physical finding of unknown etiology or significance
- Unexpected and new findings releaved by laboratory tests
- Personal or social difficulties
- Risk factors for serious conditions
- Factors crucial to remember long term
2. Controlling variables with regard to the sequencing of listed problems
includes:
- Relative gravity of the problem
- Probability/possibility ratio
- Likelihood of the probabilities in a differential diagnosis
- Availability and cost of resources relative to need and availability
- Time sequence in which the problems arose
Assessment - ANSWERS-The assessment section is composed of:
1. Your interpretations and conclusions
2. Their rationale
3. Diagnostic Strategy
,4. Present and anticipated problems
5. Needs of ongoing as well as future care
What you think!
Plan - ANSWERS-- Need to invoke diagnostic resources
- Therapeutic modalities
- Other professional resources
- Rationale for these decisions
- What you intend to do
Three sections
1. Diagnostics
2. Therapeutics
3. Patient Education
SOAP Notes - ANSWERS-1. Organization of the patient data for care beyond
the initial evaluation is often recorded in a series of SOAP notes
2. Each problem is recorded separately with subjective and objective data
relevant to each problem clustered together followed by the assessment and the
plan
3. Alternatively, all of the subjective and objective data can be recorded in
totality, then lists of problems with the assessment and plan for each are written
APSO Notes - ANSWERS-Assessment and plan is moved to beginning of the
document with all remaining data available in remainder of note
Problem-Oriented Medical Record Format - ANSWERS-1. Identifying
information
2. Problems, Allergies, Medications, Immunizations (PAMI)
,3. General patient information
4. Source and reliability of information
5. Chief concern
6. History of present illness
7. Past medical history
8. Family history
9. Personal and social history
History of Present Illness - ANSWERS-O nset
L ocation
D uration
C haracter
A ggravating/associated factors
R elieving factors
T emporal factors
S everity of symptoms
Past Medical History - ANSWERS-1. General health over patient's lifetime as
well as disabilities and functional limitations, as perceived by the patient
2. Family history with Pedigree of at least 3 generations
Personal and social history - ANSWERS-Concerns of the patient and influence
of health problem on patients life
Review of Systems (ROS) - ANSWERS-General constitutional systems
Skin, hair, nails
Head, neck
, EENT
Lymphatic
Chest and Lungs
Breasts
Heart and Blood Vessels
Peripheral vasculature
Hematologic
Gastrointestinal
Diet
Endocrine
Genitourinary
Musculoskeletal
Neurologic
Mental Health
Physical Exam Findings - ANSWERS-General statement
Mental status
Skin
Head
EENT
Neck
Chest
Lungs
Breasts
Heart
Blood Vessels
Comprehensive Health History and Physical Examination - ANSWERS-1.All
relevant data regarding the comprehensive health history should be recorded
2. Arrange the history in chronological order
3. Arrange the physical examination findings in a consistent order and style
Problem List - ANSWERS-1. A problem may be related to any of the following:
- A firmly established diagnosis
- A new symptom or physical finding of unknown etiology or significance
- Unexpected and new findings releaved by laboratory tests
- Personal or social difficulties
- Risk factors for serious conditions
- Factors crucial to remember long term
2. Controlling variables with regard to the sequencing of listed problems
includes:
- Relative gravity of the problem
- Probability/possibility ratio
- Likelihood of the probabilities in a differential diagnosis
- Availability and cost of resources relative to need and availability
- Time sequence in which the problems arose
Assessment - ANSWERS-The assessment section is composed of:
1. Your interpretations and conclusions
2. Their rationale
3. Diagnostic Strategy
,4. Present and anticipated problems
5. Needs of ongoing as well as future care
What you think!
Plan - ANSWERS-- Need to invoke diagnostic resources
- Therapeutic modalities
- Other professional resources
- Rationale for these decisions
- What you intend to do
Three sections
1. Diagnostics
2. Therapeutics
3. Patient Education
SOAP Notes - ANSWERS-1. Organization of the patient data for care beyond
the initial evaluation is often recorded in a series of SOAP notes
2. Each problem is recorded separately with subjective and objective data
relevant to each problem clustered together followed by the assessment and the
plan
3. Alternatively, all of the subjective and objective data can be recorded in
totality, then lists of problems with the assessment and plan for each are written
APSO Notes - ANSWERS-Assessment and plan is moved to beginning of the
document with all remaining data available in remainder of note
Problem-Oriented Medical Record Format - ANSWERS-1. Identifying
information
2. Problems, Allergies, Medications, Immunizations (PAMI)
,3. General patient information
4. Source and reliability of information
5. Chief concern
6. History of present illness
7. Past medical history
8. Family history
9. Personal and social history
History of Present Illness - ANSWERS-O nset
L ocation
D uration
C haracter
A ggravating/associated factors
R elieving factors
T emporal factors
S everity of symptoms
Past Medical History - ANSWERS-1. General health over patient's lifetime as
well as disabilities and functional limitations, as perceived by the patient
2. Family history with Pedigree of at least 3 generations
Personal and social history - ANSWERS-Concerns of the patient and influence
of health problem on patients life
Review of Systems (ROS) - ANSWERS-General constitutional systems
Skin, hair, nails
Head, neck
, EENT
Lymphatic
Chest and Lungs
Breasts
Heart and Blood Vessels
Peripheral vasculature
Hematologic
Gastrointestinal
Diet
Endocrine
Genitourinary
Musculoskeletal
Neurologic
Mental Health
Physical Exam Findings - ANSWERS-General statement
Mental status
Skin
Head
EENT
Neck
Chest
Lungs
Breasts
Heart
Blood Vessels
