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?
Accurate documentation of patient demographics and vital signs forms the foundation of a comprehensive health assessment. Demographic data assist clinicians in identifying the patient and understanding social, biological, and cultural factors that may influence health outcomes. Essential demographic elements include patient initials, age, height, weight, sex assigned at birth, gender identity, and race or ethnicity. Additional identifiers such as marital status and preferred pronouns promote respectful, patient-centered care.
Vital signs provide immediate insight into the patient’s physiological status and are critical for detecting acute or chronic health concerns. These include body temperature, respiratory rate, heart rate, blood pressure, and body mass index (BMI), which together help establish baseline health parameters and guide clinical decision-making.
| 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 succinctly identifies the primary reason the patient is seeking medical care, typically expressed in the patient’s own words. This statement guides the focus of the encounter and prioritizes clinical evaluation.
The history of present illness (HPI) expands upon the chief complaint by providing a chronological and detailed account of the patient’s current condition. This includes the onset of symptoms, duration, location, severity, quality, aggravating or alleviating factors, and associated symptoms. A well-documented HPI supports accurate diagnosis, continuity of care, and evidence-based treatment planning.
Medications and Allergies
Which medications and allergies should be documented?
Medication documentation requires a complete and current list of all prescribed, over-the-counter, and supplemental agents the patient is taking. Each medication should include the name, dosage, route, frequency, and clinical indication to minimize medication errors and drug interactions.
Allergy documentation is equally critical and must specify the allergen as well as the type of reaction experienced, distinguishing between true allergies and intolerances. This information is essential for patient safety and risk reduction.
| Medication Name | Dose and Directions | Indication |
|---|---|---|
Allergies and Reactions:
All known allergies should be clearly identified along with the patient’s documented reaction.
Past Medical History (PMH)
What elements should be included in past medical history?
Past medical history provides context for the patient’s current health status and risk profile. This section includes a record of previous illnesses, chronic conditions, hospitalizations, and surgical procedures, with approximate dates when available.
Immunization history is a key component of PMH and should reflect current preventive care standards. Documentation should include the most recent influenza, pneumococcal, and tetanus vaccinations to assess protection against preventable diseases.
| Past Medical History | Description or Dates |
|---|---|
| Surgeries | |
| Vaccinations | Flu: _______ |
| Pneumovax: _______ | |
| Tetanus: _______ |
Family History
How should family history be recorded?
Family history identifies genetic, hereditary, and shared environmental risk factors that may predispose the patient to certain conditions. Significant illnesses such as cardiovascular disease, diabetes, cancer, or autoimmune disorders should be documented for first- and second-degree relatives.
Each condition should be linked to the specific family member affected, along with their current living status or age at death, to assist in risk stratification and preventive planning.
| 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?
Personal and social history explores lifestyle behaviors and environmental influences that significantly impact health outcomes. This includes tobacco, alcohol, and substance use, as well as physical activity patterns and adherence to safety practices such as seatbelt and helmet use.
Additional considerations include education level, literacy, language proficiency, occupation, financial or insurance concerns, and the presence of a reliable support system. Access to transportation, communication resources, religious beliefs affecting care, hobbies with potential health risks, and sexual history further contribute to a holistic understanding of the patient’s health context.
| 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 |
| Sexual History |
Review of Systems (ROS)
How is the review of systems conducted and documented?
The review of systems is a systematic screening of major body systems to identify symptoms the patient may not have mentioned during the HPI. Each system is reviewed for the presence or absence of symptoms, with negative findings documented to demonstrate completeness.
Positive findings are described in greater detail and correlated with information from the HPI or past medical history, supporting diagnostic accuracy and comprehensive care.
| 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 | Appetite changes, nausea, pain, bowel changes |
| Urinary | Frequency, dysuria, hematuria |
| Male Genitourinary | 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 |
| Hematologic | Easy bruising, anemia, transfusion history |
Physical Examination
What observations and system examinations are important during physical assessment?
The physical examination integrates objective findings obtained through inspection, palpation, percussion, and auscultation. General observations include appearance, level of consciousness, nutritional status, posture, mobility, mood, affect, speech, and hygiene.
System-based examination encompasses the head and neck, thorax, cardiovascular, abdominal, musculoskeletal, neurological, endocrine, and psychiatric systems. A structured approach ensures abnormalities are identified and documented accurately.
Neurological assessment specifically includes cranial nerve evaluation (I–XII), sensory and motor function, coordination, reflexes, and assessment for meningeal signs.
Focused Orthopedic Examination
How are specific orthopedic tests documented?
A focused orthopedic examination evaluates joint integrity, muscle strength, ligament stability, and nerve involvement. The selection of tests is guided by the patient’s symptoms and anatomical region involved. Each maneuver should be documented with the area assessed, clinical purpose, and whether findings are normal or abnormal to support diagnostic reasoning.
| Test Name | Area Assessed | Purpose | Result (Normal/Abnormal) |
|---|---|---|---|
| Scoliosis Check | Spine | Assess spinal curvature | |
| Straight Leg Test | Lower back/leg | Identify nerve root irritation | |
| Femoral Stretch Test | Lower back/leg | Evaluate femoral nerve | |
| Empty Can Test | Shoulder | Assess supraspinatus integrity | |
| Drop Arm Test | Shoulder | Detect rotator cuff tear | |
| Apley Arm Test | Shoulder | Evaluate joint mobility | |
| Hawkins-Kennedy Test | Shoulder | Identify impingement | |
| Neer Test | Shoulder | Detect impingement | |
| Tinel Test | Wrist | Assess median nerve irritation | |
| Phalen Test | Wrist | Evaluate carpal tunnel syndrome | |
| Varus Stress Test | Knee | Assess lateral ligament stability | |
| Valgus Stress Test | Knee | Assess medial ligament stability | |
| Anterior Drawer Test | Knee | Evaluate ACL integrity | |
| Posterior Drawer Test | Knee | Evaluate PCL integrity | |
| McMurray Test | Knee | Detect meniscal injury |
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier.
Bickley, L. S. (2024). Bates’ guide to physical examination and history taking (14th ed.). Wolters Kluwer.
D117 Advanced Health Assessment Documentation Form
Course Hero. (2025). Advanced health assessment documentation form. Adapted from course materials.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). ANA.