ECU College of Nursing
AGNP/FNP Concentrations
Guidelines for H&P
(This is an example and only a guide. Please refer to your specific course/faculty for H&P
expectations.)
Student name: ___________________________ Date submitted: ________________
Faculty reviewer: ________________________
Patient Profile
Identifying Information (Initials only, age, gender, race
General Patient Information
Source and Reliability of Information
CHIEF COMPLAINT in patient’s own words and duration
HPI (use PQRST or OLDCARTS to describe complaint) Describe the course of the patient=s illness.
Cover the following 7 variables in order:
1. Location: Where the symptom is located (area it covers and any radiation. Provide a clear and
exact description of the location using anatomical terms.)
2. Quality: The character of the symptom (dull, aching, sharp, etc.)
3. Quantity of severity: Quantify the symptoms-Address how much or how
bad-10pt. scale
4. Timing: Onset, duration, and frequency. Exact sequence of events from
beginning of one typical episode according to the patient, the Astory@ of this complaint
5. Setting: Circumstances of occurrence, activities at the time of occurrence,
place, witnesses
6. Aggravating and alleviating factors: What makes the symptom better of worse, including
medications (provide dose and regimen)
7. Associate manifestations: Associated phenomena, problems, and
symptoms Also describe all pertinent negative sx related to chief
complaint in chronological order, dating events and sx.
PMH
Major childhood illnesses
Major adult illnesses
Serious Injuries
Hospitalizations and or surgery
Immunizations
Medications (Past, current, recent)
Allergies
Transfusions
Emotional Status (Mood disorders, psychiatric attention, medications)
Recent lab tests (Cholesterol, Pap smear, mammogram, PSA and results)
Family History (Includes 3 generations and genogram, specifies family hx of major health or genetic
disorders)
Personal and Social History
Cultural background and practices
Home conditions/social situation
Occupation (includes exposure to heat & cold, industrial toxins, protective devices required and used,
military service)
Current health Habits/risk factors (exercise, smoking, obesity/weight control, alcohol intake,
recreational drugs, etc.)
Exposure to chemicals, toxins, poisons, asbestos, radioactive material, caffeine)
Sexual activity (Contraception, barriers, past STI’s, screening for STIs including HIV and Syphilis
along with treatment)
Concerns about health care
Review of Systems
General Constitutional
Diet (Appetite, preferences, restrictions, supplements, caffeine, food diary or 24 hr recall
Skin, hair and nails
Head and Neck
Eyes (visual acuity, blurring, double vision, use of glasses, eye drops, medications, hx trauma or
family hx eye disease
Ears (hearing loss, pain, discharge, tinnitus, vertigo)
Nose (smell, colds, obstruction, nosebleeds, post nasal discharge, sinus pain)
Throat and Mouth (Hoarseness or change in voice; freq sore throats,
bleeding or swelling of the gums, recent abscesses, soreness of the tongue, ulcers, disturbances of
taste)
Endocrine (Thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change,
polydipsia, polyuria, changes in facial or body hair, increased hat /glove size, skin striae)
Males: Puberty onset, erections, emissions, testicular pain, libido, infertility
Females: Menarche, regularity, duration, and amount of flow, dysmenorrheal, LMP, intermenstrual
discharge or bleeding, itching, date of last Pap, age at menopause, libido, frequency of intercourse,
sexual difficulties, infertility, gravidity and parity, number and duration of each pregnancy, delivery
method, complications of pregnancy or postpartum period, use of contraceptives
Breasts (Pain, tenderness, discharge, lumps, galactorrhea, mammograms, frequency of BSE)
Chest and Lungs (Pain with respiration, dyspnea, cyanosis, wheezing, cough, sputum
character/quantity, hemoptysis, night sweats, Tb exposure, last chest x-ray)
Heart &Blood vessels (Chest pain or distress, precipitating causes, timing and duration, relieving
factors, palpitations, dyspnea, orthopnea, edema, claudication, hypertension, previous MI, exercise
tolerance, past cardiac tests)
Hematologic (Anemia, bruising/bleeding tendency, thromboses, thrombophlebitis, blood disorders,
transfusions)
Lymphatic (Enlargement, tenderness, suppuration)
GI (Appetite, digestion, food intolerance, dysphagia, heartburn, nausea, vomiting, hematemasis,
bowel regularity, constipation, diarrhea, change in stool color or contents, flatulence, hemorrhoids,
hepatitis, jaundice, dark urine, ulcer history, gallstones, polyps, tumor, previous studies)
GU (Dysuria, flank or suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy,
dribbling, loss in force of stream, passage of stone, facial edema, stress incontinence, hernias, STD’s)
Musculoskeletal (Joint stiffness, pain, restriction of motion, swelling, redness, heat, bony deformity)
Neurologic (Syncope, seizures, weakness, paralysis, problems with sensation or coordination,
tremors)
Psychiatric (Depression, mood changes, difficulty concentrating, nervousness, tension, suicidal
thoughts, irritability, sleep disturbances)
Objective: Physical Examination
General (age, race, sex, general appearance, Height, weight, BMI, vital signs.
Mental Status (Physical appearance/behavior, LOC, response to questions
Skin ( Color, uniformity, integrity, texture, temperature, turgor, hygiene, tattoos, scars, edema,
moisture, excessive perspiration, unusual odor, mobility, lesions, parasites, trauma, hair, nails)
Head (Size and contour, symmetry, facial features, edema, temporal arteries)
Eyes (visual acuity, orbits, EOM’s, Pupils, fundiscopic)
Ears (Configuration, position, alignment of auricles, otoscopic findings, hearing)
Nose (External appearance, patency, discharge, crusting, flaring, turbinates, septum, sinus
tenderness, swelling, smell)
Throat and Mouth (Number, occlusion and condition of teeth, missing teeth, presence of dental
appliances, lips, tongue, buccal/oral mucosa, floor of mouth, appearance of oropharynx, tonsils,
palate, tongue symmetry/movement, soft palate, uvula, gag reflex, taste discrimination)
Neck (fullness, mobility, strength, trachea, thyroid)
Chest (Size and shape, AP/Transverse diam, symmetry with respiration, retractions, accessory
muscles, diaphragmatic excursion)
Lungs (Respiratory rate, depth, regularity, quietness/ease of respiration, symmetry and quality of
tactile fremitus, quality & symmetry of percussion note, breath sounds, cough characteristics,
presence of friction rub, egophony, bronchophony, whispered pectoriloquy, vocal resonance)
Breasts (Size, contour, symmetry, consistency, masses, scars, thickening, retractions, dimpling,
nipples, areola, discharge)
Heart (PMI, rate, rhythm, thrills, heaves, lifts, S1,S2, murmurs, rubs, gallops, extra heart sounds)
Blood Vessels (amplitude/symmetry pulses, jugular vein pulsations, bruits, temperature, color, hair
distribution, appearance of extremities, edema, venous distention varicosities, Homan’s sign
Abdomen (Shape, contour, visible pulsations, bowel sounds, palpation findings, percussion findings,
liver span, CVA tenderness)
Male genitalia (external genitalia, urethral discharge, pubic hair, testes, hernia/scrotal swelling)
Female genitalia (external genitalia, vaginal mucosa, cervix, discharge, odor, bimanual findings,
rectovaginal exam, urinary incontinence with valsalva)
Anus and Rectum (Sphincter tone, hemorrhoids, fissures, rectal wall contour, tenderness, prostate
size contour, consistency, stool color/consistency)
Lymphatics ( lymph nodes in head, neck, clavicular, epitrochlear, axillary, inguinal areas, redness,
streaks)
Musculoskeletal (posture, symmetry of muscle mass, tone, strength, fasiculations, spasms,
active/passive ROM, pain with movement)
Neurologic (Cranial nerves, gait, balance, coordination, sensory function, superficial and DTR’s
ASSESSMENT AND PLAN:
You will include your actual diagnoses, numbers 1, 2, 3, etc based on priority and then detail your
plan for each diagnoses. You will note the differentials that you ruled out and why you ruled them
out. You will include all medications, therapeutic interventions, interprofessional referrals/other
professionals that need to be involved with recommendations, advanced care planning, follow-up
plan and patient/family education. Include anticipatory guidance, health promotion and health
maintenance. Support your decisions with evidence-based guidelines and cite your references in
correct APA format.