Complete Health Assessment Notes Based on Weber's Health Assessment Book
1. Purpose, Process, and Principles of Interview
Purpose:
- To gather comprehensive data about the client's health.
- To establish a therapeutic relationship.
- To identify health concerns and form a baseline for care planning.
Process:
- Introduction and explanation of the interview.
- Establishing rapport.
- Asking open-ended and focused questions.
- Active listening and therapeutic communication.
- Summarizing and validating information.
Principles:
- Privacy and confidentiality.
- Respect and empathy.
- Objectivity and non-judgmental approach.
- Use of effective verbal and non-verbal communication.
2. Content and Format Used in the Health History
Content:
- Biographical data
- Chief complaint
- History of present illness
- Past medical and surgical history
- Family history
- Lifestyle and personal habits
- Psychosocial history
- Review of systems
Format:
- Organized, usually head-to-toe or system-based.
- Structured either in narrative or checklist style.
- Uses standard medical terminology.
3. Investigating Positive Findings During Health History
- Clarify symptoms: onset, duration, severity, triggers.
- Use OLDCARTS or PQRST framework.
- Ask follow-up questions related to functional impact.
- Compare with baseline data.
- Document clearly and notify healthcare team if necessary.
4. Practice Obtaining and Recording Client Health History
- Use a structured interview guide.
- Ask open-ended questions.
- Record findings systematically.
- Summarize and validate with the client.
5. Practice Utilizing Therapeutic Skills with a Learner's Partner
- Role-play client-nurse interactions.
- Apply active listening, reflection, empathy.
- Maintain appropriate eye contact and body language.
- Give and receive feedback for improvement.
6. Identify Strengths and Weaknesses via Videotaped Interaction and Self/Peer Analysis
- Watch the recording critically.
- Use a checklist or rubric.
- Identify strong communication skills (e.g., listening, empathy).
- Note areas for improvement (e.g., interrupting, closed questions).
- Reflect on verbal and non-verbal cues.
7. Interview the Client in a Clinical Setting and Collect Feedback
- Prepare the environment and introduce yourself.
- Conduct a full interview using therapeutic techniques.
- Use open-ended questions and clarify concerns.
- Afterward, request structured feedback from peers and instructors.
- Reflect on your performance and set improvement goals.
8. General Principles of Conducting an Examination
- Wash hands and gather equipment.
- Explain procedure to the patient.
- Ensure privacy and comfort.
- Follow a head-to-toe or system-based approach.
- Begin with inspection, then palpation, percussion, auscultation.
- Modify approach for children or elderly.
- Document promptly and professionally.
9. Procedure and Sequence for Performing a General Assessment
- Start with introduction and consent.
- Observe general appearance.
- Measure vital signs and anthropometrics.
- Assess mental status and mobility.
- Note nutritional status.
- Follow head-to-toe approach.
10. Guidelines for Documenting Physical Examination
- Be accurate, objective, and timely.
- Use standard medical terminology.
- Record both normal and abnormal findings.
- Follow a systematic format.
- Use approved abbreviations.
- Sign, date, and time each entry.
11. Physical Examination Documentation Example (Ongoing Basis)
Patient Name: Sarah Thomas
Age: 52
Date: 24/05/2025
Time: 10:00 AM
Examiner: A. Sharma, SN
General Appearance: Patient alert and oriented x3. Calm, cooperative, and well-nourished. No
acute distress.
Vital Signs: T: 98.6°F | P: 76 bpm | R: 18 bpm | BP: 126/78 mmHg | SpO2: 98% | Pain: 2/10
Skin: Warm, dry, intact. No rashes or lesions.
HEENT: Normocephalic, pupils PERRLA, hearing intact, no nasal discharge, oral mucosa pink.
Neck: Trachea midline, no lymphadenopathy.
Chest/Lungs: Lungs clear bilaterally. Symmetrical chest expansion.
Heart: Regular rate and rhythm, no murmurs.
Abdomen: Soft, non-tender, bowel sounds active.
Musculoskeletal: Ambulates independently. No deformities or tenderness.
Neurological: Alert, oriented, cranial nerves II-XII intact. Strength 5/5.
Signature: A. Sharma, Student Nurse
Next Review: 25/05/2025
