fbpx

Health Assessment

A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history. It is done to detect diseases early in people that may look and feel well.

Evidence does not support routine health assessments in otherwise healthy people.[1]

Health assessment is the evaluation of the health status of an individual along the health continuum.[2] The purpose of the assessment is to establish where on the health continuum the individual is because this guides how to approach and treat the individual. The health care approaches range from preventive, to treatment, to palliative care in relation to the individual’s status on the health continuum. It is not the treatment or treatment plan. The plan related to findings is a care plan which is preceded by the specialty such as medical, physical therapy, nursing, etc.

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.hjkiuy65tg

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

P.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

As you continue reading remember that our top and qualified writers are here to help with any of your assignment. All you need to do is place an order with us.

 

what are the five stages of a health assessment?The five phases are:

  • Assessment. When you first encounter a patient, you will be expected to perform an assessment to identify the patient’s health problem(s) as well as their physiological, psychological, and emotional state. …
  • Diagnosis. …
  • Planning. …
  • Implementation. …
  • Evaluation.

What is the process of health assessment?

A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.

What are health assessment tools?

Assess your health with interactive tools such as calculators, quizzes, and questionnaires. You can check your risk for heart disease, calculate your ideal weight and body mass, find out how many calories your favorite exercise burns, and more.

Does this Look Like Your Assignment? We Can do an Original Paper for you!

Here's Are the answers to Frequently Asked Questions

A Page will cost you $12, however, this varies with your deadline. 

Enjoy the convenience of having a reliable Writer to do your paper at an Affordable Price.  With our premium writing service, you no longer have to spend days and nights meticulously working on your assignment, instead use that time to do other important things. 

Upon completion, we will send the paper to you via email and in the format you prefer (word, pdf or ppt). 

Yes, we have an unlimited revision policy. If you need a comma removed, we will do that for you in less than 6 hours, if you need a full paper review we are always available to handle your request. 

As you Share your instructions with us, there’s a section that allows you to attach as any files. Please include all the details and files useful to the writer. You can also provide a sample of your work, so that the writer can write just like you!

Yes, through email and messages, we will keep you updated on the progress of your paper. 

Start by filling this short order form thestudycorp.com/order 

And then follow the progressive flow. 

Having an issue, chat with us here

Regards,

Cathy, CS. 

Have no Time to Write? Let a subject expert write your paper for You​
Scroll to Top