Comprehensive Health assessment Instructions

The health history should incorporate the following: - Biographical Data including allergies - Reason for seeking care - History of Current Illness - Past Medical History - Family History (including Genogram) - Social History/ Functional assessment - Review of Systems Genograms can be created on a word document using shapes under the insert tab, or they can be drawn by hand, scanned and uploaded. Genograms must look professional and neat. If the genogram is turned in and is not legible or professional, the assignment will receive a grade of zero (0) points towards that part of the grade. The genogram is to be included as part of the comprehensive health history. In addition to the findings from the history and physical exam, your write up also needs to include a problem list and an SBAR communication. The problem list should be complete and include all pertinent health concerns that need consideration or intervention. Finally, the findings from comprehensive history, physical exam and problem list should be summarized into an SBAR communication report. The SBAR Communication Report should follow the following format: SBAR Communication Report Situation (one sentence description of need) Background (details that give an assessment) Assessment (your position on the issue) Recommendation (your specific method for solving the problem)

Vitals Model Documentation • Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F Health History Model Documentation Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. General Survey Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Reason for Visit "I came in because I'm required to have a recent physical exam for the health insurance at my new job."

effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago. Health Maintenance Last Pap smear 4 months ago. Last eye exam three months ago. Last dental exam five months ago. PPD (negative) ~2 years ago. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine for college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room. Family History • Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems Social History

Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming. Mental Health History Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear. Review of Systems - General No recent or frequent illness, fatigue, fevers, chills, or night sweats. States recent 10 pound weight loss due to diet change and exercise increase. HEENT Model Documentation Subjective Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.

Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves or lifts. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema. Abdominal Model Documentation Subjective Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching. Objective Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness. Musculoskeletal Model Documentation Subjective Reports no muscle pain, joint pain, muscle weakness, or swelling. Objective Bilateral upper and lower extremities without swelling, masses, or deformity and with full range of motion. No pain with movement. Neurological Model Documentation Subjective Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.

Objective Strength 5/5 bilateral upper and lower extremities. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces. Skin, Hair & Nails Model Documentation Subjective Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes. Objective Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Rubric Name: Comprehensive Health History and Physical Exam with Write-Up Criteria Level 3 Level 2 Level 1 Shadow Health SPI Score 15 points (11-15 points) 86-100 10 points (6-10 points) 71-85 5 points 70 Biographical Data 3 points 2 points 1 point

(9-12 points) Includes three generations of family members, clearly states relationships and major illnesses, includes ages and names, using appropriate symbols, identifies health risk factors across all generations and all known causes of death (5-8 points) Incomplete family structure, less than three generations of family, some errors in demonstrating relationships using appropriate symbols. Some information regarding ages and names of family members are missing, Identifies medical diagnosis of a few family members, does not state causes of death (0-4 points) Less than three generations, relationships are unclear, Missing most of the information regarding family member names or ages. Does not state medical diagnosis of family members, does not state causes of death Review of Systems 5 points (4-5 points) Completely covers all systems. Identifies co- existing problems, describes positive reactions clearly 3 points (2-3 points) Missing few systems 1 point (0-1 points) Missing many systems Social and Functional Assessment 5 points (4-5 points) Fully assess ability to perform activities of daily living or environmental concerns. Includes information regarding finances, 3 points (2-3 points) Missing information regarding patients ability to perform activities of daily living or environmental concerns 1 point (0-1 points) Little to no information regarding patients ability to perform activities of daily living, does not address environmental

occupation, religion, hobbies, sleep, exercise and diet. concerns Physical Examination 20 points (13-20 points) Complete documentation of each body system examined. Findings are clearly described 12 points (7-12 points) Some parts of the exam performed are missing, few errors in describing findings 6 points (0-6 points) Many parts of the exam performed are missing, frequent errors in describing findings Problem List 4 points ( 4 points) Lists all pertinent health concerns. Provides a clear picture of the patient’s health problems that require consideration or intervention 3 points ( 2-3 points) Mostly based on history and physical exam findings 1 point (0 - 1 points) Little/vague connection to patient history or physical exam findings SBAR Communication 10 points (8-10 points) Completely documents: situation, background, assessment and recommendations 7 points (4-7 points) Situation, background, assessment or recommendations are not clearly described. 3 points (0-3 points) Incomplete documentation, unclear regarding situation, assessment recommendation and/or recommendation Organization of Write-up, use of 3 points 2 points 1 point