Advanced Health Assessment

Advanced Health Assessment

  1. Please select a volunteer friend or family member to interview and gather data to complete this Assignment.
  2. This section of the SOAP note will include the chief complaint, history of present illness, and family/social/personal history data.
  3. Click here for the written guide for this Assignment.
    1. The guide will assist you in gathering subjective data in an organized, systematic manner to prevent omission of important components of the health history.
    2. Make sure you address all content as noted in the written guide.
    3. Include the genogram together with this Assignment as one document. Advanced Health Assessment
    4. You may search the Web to locate a suitable genogram diagram to input data. Only include three generations in the genogram depiction

History, Interview, and Genogram Guide

Please select a volunteer friend or family member to interview and gather data to complete this Assignment. The following guide will assist you in gathering subjective data in an organized, systematic manner to prevent omission of important components of the health history. Please remember to attach a Genogram with this Assignment as one document, if possible. You may search the web to locate a suitable Genogram diagram to input data. Only include 3 generations in the genogram depiction. Advanced Health Assessment

Date of History/Interview:

Source of history and Reliability: (client, family member, chart/record, etc.-sample on page 50 of Jarvis textbook)

1. Biographical Data

a. Name (use initials only)

b. Address

c. Phone number

d. Primary language

e. Authorized representative Advanced Health Assessment

f. Age and Date of Birth

g. Place of Birth

h. Gender

i. Race

j. Marital Status

k. Ethnic/Cultural Origin

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l. Education ( highest level completed)

m. Occupation/Professional

n. Health insurance Advanced Health Assessment

2. Chief Complaint (reason for seeking health care):

a. Brief spontaneous statement in client’s own words

b. Includes when the problem started ( “chest pain for 2 hours”)

3. History of Present Illness: A well organized, chronological record of client’s reason for seeking care, from time of onset to present. Please include the 8 critical characteristics using the PQRSTU pneumonic.

P – Provocative or palliative (What brings it on? What makes it better or worse?)

Q – Quality or quantity (Describe the character and location of the symptoms; How does it look, feel, sound?) Advanced Health Assessment

R – Region or radiation (Where is it? Does the symptom radiate to other areas of the body?).

S – Severity (Ask the patient to quantify the symptom(s) on a scale of 0-10).

T – Timing (Inquire about time of onset, duration, frequency, etc.)

U – Understand Patient’s Perception of the problem (What do you think it means?)

4. Past Medical History

a. Medical Hx: major illnesses during life span, injuries, hospitalizations, transfusions, and disabilities

b. Childhood Illnesses: Measles, mumps, rubella, chickenpox, pertussis, strep throat

c. Surgical Hx; procedures, dates, inpatient or outpatient Advanced Health Assessment

d. Obstetric HX: Number of pregnancies, term deliveries, preterm births, abortions

(spontaneous or induced), number of children living

e. Immunizations

f. Psychiatric Hx: childhood and adult (treated or hx of) Advanced Health Assessment

g. Allergies: Medications, food, inhalants or other (what occurs with reaction)

h. Current Medications: Include all prescription, herbal/supplements and OTC, dosage, frequency

i. Last Examination Date: Physical, eye exam, foot exam, dental exam, hearing screen, EKG, chest X-Ray, Pap test, mammogram, serum cholesterol, stool occult blood, prostate, PSA, UA, TB skin test; other health maintenance tests for infants/children may include sickle-cell, PKU, lead level, and hematocrit Advanced Health Assessment

5. Family History (list FHx and design a genogram (computer)-include a key with the genogram). The Genogram must include 3 generations.

a. Include parents, grandparents, spouse, and children.

b. Health conditions, familial and communicable diseases/illnesses

c. Note whether family member deceased or living Advanced Health Assessment

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