When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Assignment, you begin to plan and write a comprehensive assessment that focuses on one female patient from your current practicum setting.
- Reflect on your Practicum Experience and select a female patient whom you have examined with the support and guidance of your Preceptor.
- Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, treatment and management plan, as well as education strategies and follow-up care.
Write an 8- to 10-page comprehensive assessment that addresses the following:
- Age, race and ethnicity, and partner status of the patient
- Current health status, including chief concern or complaint of the patient
- Contraception method (if any)
- Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
- Review of systems
- Physical exam
- Labs, tests, and other diagnostics
- Differential diagnoses
- Management plan, including diagnosis, treatment, patient education, and follow-up care