D117 Advanced Health Assessment Documentation Form

D117 Advanced Health Assessment Documentation Form

Student Name

Western Governors University

D117 Advanced Health Assessment for the Advanced Practice Nurse

Prof. Name:

Date

D117 Advanced Health Assessment Documentation Form

Patient Demographics and Vital Signs

What are the key demographic details and vital signs to be documented?

Patient demographics include initials, height, weight, age, sex assigned at birth, gender identity, and race/ethnicity. Additional information such as marital status, preferred pronouns, body mass index (BMI), and temperature is essential. Vital signs to record include respiratory rate, heart rate, and blood pressure.

Parameter	Details to Document
Patient Initials
Height
Weight
Age
Sex Assigned at Birth
Gender Identity
Body Mass Index (BMI)
Temperature
Respiratory Rate
Heart Rate
Blood Pressure
Race/Ethnicity
Marital Status
Preferred Pronouns

Chief Complaint and History of Present Illness (HPI)

What is the patient’s main concern and current illness history?

The chief complaint captures the primary reason for the patient’s visit. The history of present illness (HPI) provides a detailed, focused description of the orthopedic or other medical issues, including onset, duration, severity, and associated symptoms.

Medications and Allergies

Which medications and allergies should be documented?

List all current medications, including the name, dosage, directions, and indication for use. Allergies should be recorded with details on the specific allergen and the reaction experienced.

Medication Name	Dose and Directions	Indication

Allergies and Reactions:
Specify all known allergies and the nature of reactions.

Past Medical History (PMH)

What elements should be included in past medical history?

Include any relevant past illnesses, hospitalizations, chronic conditions, and surgeries with dates. Vaccination history should also be documented, including dates for flu, pneumococcal, and tetanus vaccines.

Past Medical History	Description or Dates
Surgeries
Vaccinations	Flu: _______
	Pneumovax: _______
	Tetanus: _______

Family History

How should family history be recorded?

Document any significant diseases within the family, specifying the affected relative (mother, father, siblings, maternal/paternal grandparents) and noting whether they are alive or the age at death.

Family Member	Diseases/Conditions (If Applicable)	Alive or Age at Death
Mother
Father
Siblings
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather

Personal and Social History

What social and personal factors affect health?

Social history includes tobacco and alcohol use, substance abuse, exercise habits, safety practices (e.g., seatbelt and helmet use), education level, literacy, language, occupation, financial concerns, and support systems. Additional factors include transportation access, communication means (phone/internet), religion and related health considerations, hobbies, and sexual history.

Personal/Social Factor	Information to Document
Tobacco Use	Current/former, years started/stopped, amount/day
Alcohol Consumption
Substance Abuse
Exercise Habits
Safety Habits	Seatbelt use, helmet use, texting while driving
Education Level
Literacy and Language
Occupation
Financial/Insurance	Concerns or status
Support System	Family, friends
Transportation	Method used
Phone/Internet Access
Religion and Health Needs	E.g., refusal of blood products
Interests and Hobbies	Include health risks associated
Sexual History

Review of Systems (ROS)

How is the review of systems conducted and documented?

ROS involves screening multiple body systems for symptoms or signs. Each system is checked for negative or positive findings. Positive findings are further described with detailed attributes from the HPI or PMH.

Body System	Symptoms/Findings to Assess
General	Weight changes, weakness, fatigue, fever, pain
Skin	Rash, lumps, sores, itching, dryness, color changes
Head	Headache, injury, dizziness
Eyes	Vision changes, corrective lenses, pain, redness
Ears	Hearing loss, tinnitus, infections
Nose and Sinuses	Congestion, discharge, itching, nosebleeds
Throat	Bleeding gums, dentures, sore throat, hoarseness
Neck	Lumps, swollen glands, stiffness, swallowing difficulty
Breasts	Lumps, pain, nipple discharge
Pulmonary	Cough, hemoptysis, dyspnea, wheezing
Cardiac	Chest pain, palpitations, dyspnea, edema
Gastrointestinal (GI)	Appetite changes, nausea, pain, bowel habit changes
Urinary	Frequency, dysuria, hematuria
Male Genitourinary	Urinary stream caliber, discharge, testicular pain
Female Genitourinary	Menstrual history, discharge, menopause symptoms
Peripheral Vascular	Claudication, leg cramps, varicose veins
Musculoskeletal	Muscle/joint pain, stiffness, instability
Neurological	Syncope, seizures, weakness, numbness, tremors
Hematologic	Easy bruising, anemia, blood transfusions

Physical Examination

What observations and system examinations are important during physical assessment?

A comprehensive physical exam assesses general appearance, head and face, eyes, ears, nose, mouth, throat, neck, thorax (anterior, posterior, lateral), cardiovascular, abdomen, neurological, and musculoskeletal systems. Additional endocrine and psychiatric evaluations are included.

General Observations:

• Appearance (well or ill-appearing)

• Level of consciousness

• Nutritional status and body habitus

• Deformities or mobility issues

• Mood and affect

• Speech and hygiene

Neurological Examination Includes:

• Cranial nerve testing (I through XII)

• Coordination and sensory testing

• Reflexes (deep tendon)

• Meningeal signs

Focused Orthopedic Examination

How are specific orthopedic tests documented?

The orthopedic assessment involves a series of specific tests depending on the region examined. Examples include:

Test Name	Area Assessed	Purpose	Result (Normal/Abnormal)
Scoliosis Check	Spine	Check for spinal curvature
Straight Leg Test	Lower back/leg	Assess nerve root irritation
Femoral Stretch Test	Lower back/leg	Evaluate femoral nerve involvement
Empty Can Test	Shoulder	Assess supraspinatus muscle integrity
Drop Arm Test	Shoulder	Detect rotator cuff tear
Apley Arm Test	Shoulder	Evaluate shoulder joint mobility
Hawkins-Kennedy Test	Shoulder	Identify impingement syndrome
Neer Test	Shoulder	Detect shoulder impingement
Tinel Test	Wrist	Assess median nerve irritation (carpal tunnel)
Phalen Test	Wrist	Evaluate for carpal tunnel syndrome
Varus Stress Test	Knee	Check lateral ligament stability
Valgus Stress Test	Knee	Check medial ligament stability
Anterior Drawer Test	Knee	Assess anterior cruciate ligament (ACL)
Posterior Drawer Test	Knee	Assess posterior cruciate ligament (PCL)
McMurray Test	Knee	Detect meniscal tears

References

(Adapted and rephrased from Advanced Health Assessment Documentation Form. CourseHero.com. Retrieved December 20, 2025, from https://www.coursehero.com/file/229774868/Advanced-Health-Assessment-Documentation-Formpdf/)