PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations):
Significant Family History:
Social/Personal History (occupation, lifestyle—diet, exercise, substance use)
Description of Client’s Support System:
Behavioral or Nonverbal Messages:
Client Awareness of Abilities, Disease Process, Health Care Needs:
Objective Data:
Vital Signs including BMI:
Physical Assessment Findings:
Lab Tests and Results:
Client’s Support System:
Client’s Locus of Control and Readiness to Learn:
ICD-10 Diagnoses/Client Problems:
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
References
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