RNotes®: Nurse’s Clinical Pocket Guide 3rd Edition
Biographical Data: Record Pt’s name, age, and date of birth, gender, race, ethnicity, nationality, religion, marital status, children, level of education, job, and advance directives.
■ Chief Complaint (subjective): What the Pt tells you. Symptom analysis for chief complaint. Chief complaint should not be confused with medical diagnosis (e.g., Pt complaining of nausea and is later diagnosed with MI; chief complaint is nausea and is documented as such even though the medical diagnosis may be evolving MI).
■ Past Health History: Record childhood illnesses, surgical procedures, hospitalizations, serious injuries, medical problems, immunization, and recent travel or military service.
■ Medications: Prescription medications taken regularly as well as those taken only when needed (prn). Note: prn medications may not be used very often and are likely to be expired. Remind Pts to replace expired medications. Inquire about OTC drugs, vitamins, herbs, alternative regimens, and use of recreational drugs or alcohol.
■ Allergies: Include allergies to drugs, food, insects, animals, seasonal changes, chemicals, latex, adhesives, etc. Try to differentiate between allergy and sensitivity, but always err on the side of safety if unsure. Determine type of allergic reaction (itching, hives, dyspnea, etc.).
■ Family History: Health status of family (parents, siblings, children, aunts, uncles, and grandparents) as well as spouse/significant other. Obtain age and cause of death of deceased family members.
■ Social History: Assess health practices and beliefs, typical day, nutritional patterns, activity/exercise patterns, recreation, pets, hobbies, sleep/rest patterns, personal habits, occupational health patterns, socioeconomic status, roles/relationship, sexuality patterns, social support, and stress coping mechanisms.
■ Physical Assessment (objective): Three types of physical assessment.
■ Head-to-toe: More complete, it assesses each region of the body (i.e., head and neck) before moving on to the next.
■ Systems assessment: More focused, it assesses each body system (i.e., cardiovascular) before moving on to the next.
■ Focused assessment: Priority of assessment is dictated by Pt’s chief complaint.
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