Comprehensive History and Physical Exam Write-Up

In this assignment, students will conduct a comprehensive health history and physical examination, including a write-up of the findings on a volunteer patient. (20% of course grade)

The health history should incorporate the following:

– Biographical Data including allergies

– Reason for seeking care

– History of Current Illness

– Past Medical History

– Family History

– Social History/ Functional assessment

– Review of Systems

After you have obtained the history, you will then need to complete a physical exam on your volunteer patient. Your exam needs to be comprehensive and include each of the body systems listed on the worksheet.

In addition to the findings from the history and physical exam, your write-up also needs to include a problem list and an SBAR communication.

The problem list should be complete and include all pertinent health concerns that need consideration or intervention.

Finally, the findings from the comprehensive history, physical exam, and problem list should be summarized into an SBAR communication report.

The SBAR Communication Report should follow the following format:

SBAR Communication Report

Situation (one-sentence description of need)

Background (details that give an assessment)

Assessment (your position on the issue)

Recommendation (your specific method for solving the problem)

After you have completed your write-up of the history, physical exam, problem list, and SBAR report, you will need to submit this, to the Comprehensive Health History and Physical Exam Write-up section in the classroom assignment folder.

When you submit your paper, please use a cover sheet, and document your findings in the appropriate format using appropriate terminology. For an example of the proper format of writing your assessment findings, please refer to the module in Week 1 titled: Communication of Assessment Findings: Preparing the Narrative, as well as the module titled: Communicating the Assessment Findings: SBAR format. There is a sample write-up located in this area.

The worksheet for the Comprehensive Health History can be found in week 1 of the activities section of the LEO classroom. This worksheet contains the information that you will need to obtain for this assignment. Please use this worksheet as a guide throughout the course to help you in obtaining the information you will need in writing your paper as well as writing the SBAR report.Comprehensive History and Physical Exam Write-Up

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