NURS680B Advanced Health/Physical Assessment
Week 5 Assignment
Comprehensive Health Assessment
Students will select a new “patient” (friend or family member) for whom they will perform and document a complete history. This will include a complete head-to-toe review of systems (ROS) and a complete head-to-toe physical examination. This will be documented in a SOAP note format.
The patient should be an adult over the age of 18 with a chief complaint. Please do not choose the same friend or family member from previous course assignments.
Document a working diagnosis and a minimum of 3 differential diagnoses. These are based on the chief complaint (CC) an history of present illness (HPI). All 3 diagnoses Working diagnosis and differential diagnoses must include pertinent positive and negative symptoms. You may also include known diagnoses, such as obesity or hypertension. These do not need pertinent findings.
NOTE: Do not use real names or initials or otherwise identify your “patient.” Failure to maintain privacy will result in a failing score
The Subjective health history and Objective physical exam must contain all required elements as outlined in Jarvis Chapter 27 (except breast and genital exams) and the attached document. The Assessment, as well as the Plan, will be focused based on CC and HPI.
Read the rubric for the Comprehensive Health Assessment assignment carefully.
The assignment submission should be a single document that contains:
A complete subjective history
A complete objective examination
Working diagnosis with at least 3 differential diagnoses with pertinent findings for each
Plan of care that includes a discussion of the national guidelines for your diagnosis and health maintenance needs for your patient