07 Oct This assignment comprises a comprehensive H&P ie l
This assignment comprises a comprehensive H&P ie like an annual history and physical examination. There does not have to be a problem. CC may be ” I am here for an annual physical exam”. Length: No more than 10 pages; not including cover page or reference page Format: Follow the template below for H&P. Follow attached ROS template. Include a title and a reference page in APA format, using proper margins. Refer to coursework and sample H&P in the Bates textbook for appropriate verbiage and terminology. Organize your paper using the main sections below. The final document should be “chart” worthy,” which means that the documentation must be succinct, clear, and convey knowledge of advanced history taking and advanced physical assessment skills. It is not be be written in paragraph form. DO NOT USE THE TERMS “NORMAL”, “GOOD, OR “WITHIN NORMAL LIMITS”, UNREMARKABLE ETC. DEDUCTIONS WILL BE MADE FOR THIS. In addition to content, you will be graded on organization, neatness, use of approved abbreviations, and correct grammar and punctuation. References: Use Bates text in citations and as a reference. PART I. Comprehensive History 1. Identifying Data – No name, only use initials, observe anonymity 2. Chief complaint – See above, use patient words using quotes 3. History of Present Illness – OLDCART is used when there is a complaint. For this assignment, you may simply state that the patient presents to establish care and he/she has no health concerns at present. 4. Medications 5. Allergies 6. Past Medical History 7. Past Surgical History 8. Family History – 3 generations, if known, (must include a genogram, illustrated by hand or computer) 9. Social History – include living arrangements, marital status, employment 10. Sexual and Reproductive History 11. Health Care Maintenance (HCM) strategies – include dental care and other health services, complementary therapies 12. REVIEW OF SYSTEMS – Ask the patient “Have you ever had problems with ….” regarding each system in detail. FOLLOW ROS TEMPLATE ATTACHED. PART II. Complete Physical Examination [exclude the pelvic exam, breast exam, genitourinary exam for male or female] 1. Vital signs: Temperature, Pulse, Respirations and Blood Pressure, Weight and Height, Body Mass Index (BMI). 2. General Survey 3. Mental Status Exam (MSE) – Document the MSE in narrative, paragraph form: 1st paragraph – summary of presentation (appearance, behaviour, speech, language) 2nd paragraph – key findings with mood & affect 3rd paragraph – thought processes 4th paragraph – cognitive function 5th & final – insight & judgment 4. Skin (include hair and nails) 5. Head (include regional lymph nodes) 6. Eyes 7. Ears 8. Nose and Sinuses 9. Mouth and Throat 10. Neck (include regional lymph nodes) 11. Respiratory (include regional lymph nodes) 12. Cardiovascular and Peripheral Vascular- include pulse rating 13. Abdomen (include regional lymph nodes) 14. Musculoskeletal – include muscle strength rating 15. Neurological – include deep tendon reflex rating Document the regional lymph nodes with the specific name of the nodes that you checked. Failure to name the specific nodes will result in point deduction (i.e. writing “no lymphadenopathy” in the neck exam is not correct. You must name the nodes you checked and what your findings were, whether abnormal or normal). Include the cranial nerves (CN) within the body system where you checked the CN. For instance, when you are examining the ear, you will document that CN VIII is intact as the pt passed the whisper test. Then in the Neurological system, if all of the CN testing demonstrates that the CNs are intact, you may chart CNI-CNXII intact. You may not document that all of the CNs are intact unless there is previous documentation that you have specifically tested the CN within the body system. Grading Rubric Content= 80% The History is worth 40% – include all components, including illustrated genogram The Physical Exam is worth 40% – include all systems Mechanics of Writing=20% Formatting, correct headings, organization, spelling, approved abbreviations only, proper use of citations and references
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