NSP6102: The Hospital or Clinic and Length of Symptoms - Nursing Assignment Help

Assignment Task:

The History & Physical (H&P) is a comprehensive note that gets written about each patient the first time that the patient is seen and/or admitted to the hospital.

Chief Complaint (CC): The main problem for which the patient is in the hospital or clinic and length of symptoms i.e. “shortness of breath for 3 days”. If post-op should be in the form of, “post-op day 3 after inguinal hernia repair”

History of Present Illness (HPI): Consists of 2 paragraphs. 1st paragraph is a brief history of what led the patient to coming in and a description of the problem, i.e. worsening shortness of breath. Tell it like a story and write events in chronological order to keep the sequence of events clear. Remember the acronym SOCRATES (site, onset, character, radiation, alleviating factors, timing, exacerbating factors, severity) to describe the patient’s presentation. The 1st paragraph should focus on the chief complaint, and give the listener an idea of the patient’s progression of symptoms (as relevant)

The 2nd paragraph is a Review of Systems (ROS), i.e. the relevant positive and negative findings that the patient tells you about after you ask them questions about their symptoms beyond “Shortness of breath” (i.e. was there any fever/chills, cough, oedema, orthopnoea, sick contacts etc.). This paragraph is where you will show clinical mentor your medical reasoning - i.e. what symptoms/signs you attempted to rule in/out to help clarify the differential diagnosis. If someone has shortness of breath, you should clarify the source as cardiac vs. pulmonary, for example, based on the questions you ask. This is where you can shine!

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