Academic clinical history and physical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, to develop and demonstrate critical thinking and clinical reasoning skills, and to practice identifying acute and chronic problems and formulating evidence-based plans of care.
Complete an academic clinical history and physical note based on a patient seen during clinical. In your assessment, provide the following.
History and Physical Note
1. Chief complaint/reason for admission/visit/consult.
2. HPI for the H&P or consult notes.
3. Medical, surgical, family, social, and allergy history.
4. Home medications, including dosages, route, frequency, and current medications, if a consultation note
5. Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).
6. Vital signs and weight.
7. Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam.
8. Lab/Imaging/Diagnostic test results (including date).
Assessment and Clinical Impressions
1. Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale.
2. Include a complete list of all diagnoses that are both acute and chronic.
3. List the differential diagnoses and chronic conditions in order of priority.
Plan Component Management and Plan Criteria Incorporation
1. Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale.
2. Discuss disposition and expected outcomes.
3. Identify and address health education, health promotion, and disease prevention.
4. Provide case summary with ethical, legal, and geriatric considerations. Consider potential issues, even if they are not evident.
Incorporate at least three to Five peer-reviewed articles in the assessment or plan. Words count should be between 1000-1500.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.