MSN 610 Discussion: HEENT Physical Exam Write Up
Northern Kentucky University
MSN 610: Diagnostic Reasoning and Advanced Physical Assessment
Comprehensive History & Physical Exam
DEMOGRAPHICS
Providers Name: ___________________________________ Patient’s Initials: (Data Source)____________________
Date of Exam: _____________________________________ Patient’s DOB/AGE: _______________
Chief Complaint: ____________________________________ Gender/Sexual Orientation: ____________________
History of Present Illness:
Past Medical History:
Active Problems:
Resolved Problems:
Previous Hospitalizations:
Surgical History:
Allergies:
Current Medications:
Social History:
Living Arrangements:
Occupation:
Environmental Safety:
Smoking:
Alcohol:
Drugs:
Diet:
Other Non-Prescribed Drugs:
Family History:
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Preventative Health/ Anticipatory Guidance: (Age Appropriate)
1. Safety Issues:
2. Screenings:
3. Immunizations:
Reproductive health:
Review of Systems:
General:
Skin, Hair, Nails:
HEENT:
Neck:
Cardiovascular:
Pulmonary:
Abd/GI:
Genitourinary/ Gynecology/ Breast:
Musculoskeletal:
Neuro:
Endo/Lymphatic:
Hematology:
Psych:
Physical Exam
Vital Signs: Temp: __________ Pulse: _______ BP: _________/________ Resp: ______ O2 sat: _________
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General:
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Head:
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Ears:
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Eyes:
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Nose:
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Throat:
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Neck:
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Assessment Statement:
Problem List (As many or as few as needed)
Include ICD – 10 CODE
1.
2.
3.
Plan:
1.
2.
3.
4.
Submitted by: __________________________________________________
Date: __________________________________________
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