Omprehensive health assessment and documentation

Choose a client to assess. They may be an adult or a child, male of female.
Conduct a comprehensive subjective (history) and objective assessment of the client. This assessment will include the following:
1. Assessment of psychosocial and spiritual status (compulsory)
2. Assessment of activity and exercise status
3. Assessment of cognitive/perceptual status
4. Assessment of nutritional/metabolic and elimination status
5. Assessment of sexuality/reproductive status.
While status 1 (psychosocial and spiritual patterns) is compulsory, you may choose any three of status 2 to 5.

Step 4
Comprehensively document your findings and prepare a report for the client s Primary Health Care Provider. Word length approximately 1500 2000 words.

Criteria 1 Legibility
Criteria 2 Grammar and spelling. Only approved abbreviations used.
Criteria 3 Conciseness. Very concise and complete.
Criteria 4 Objective documentation. All entries record objective observations with client responses clearly identified.
Criteria 5 Documentation of client s perception and understanding. All problems clearly outlined from the client s perspective
Criteria 6 Documentation completeness and comprehensiveness. All client symptoms, findings and experiences complete and comprehensive.
Criteria 7 Linkage of subjective and objective data. All subjective data linked to objective assessment and data.
.
General guidelines for the assignment
1. General presentation is to include 1.5 line spacing; 12 point font; 3cms left and right
margins, page numbering in the lower right of each page.

2. Double space between each paragraph

3. Adhere as closely as possible to the word count. A ± 10% of the word limit is acceptable.
Please indicate the word count at the conclusion.

4. Bickley, L & Szilagyi, P 2007, Bates guide to physical examination and history taking, 9th edn, J B Lippincott, Williams & Wilkins, Philadelphia.
it is possibly the most comprehensive I have found in terms of a reference book, by the manner in which it links anatomy, physiology, pathophysiology and actual assessment. A great example for documentation.