Professional Communication in Nursing Health Assessment Clinical Note

401205 Professional Communication in Nursing
Health Assessment Clinical Note
Student Number: Student Name:
Tutor’s Name: _______________________________________________________________________________
URL for Health Assessment Video: _________________________________________________
Clinical Note
Student (Community – Registered Nurse): Use professional written communication to document the
findings from the nursing health assessment during the interview with the patient
Introduction
Date: / /2019
Patient’s Name: Chester Abioye Date of birth: 14th January 2000
Address: 97 Leafy Avenue, Broadfields, 2173
Situation
Reasons for assessment, allergies, and relevant personal details: Patient does not have any allergy; he wants
to improve his health as well as change his lifestyle.
Background
(1 mark)
Health history, general health and psychosocial status: Patient has been suffering from depression in the past .
Living arrangements and family relationships: He lived alone in Australia and is working in the storeroom at Aldi.
He used to work overtime to save money so that he could send back to his family in Zambia ( Romeo, 2017). He has a
girlfriend with whom he enjoys talking and mailing on the computer.
Assessment
(1 mark)
Observations, height, weight (shape): Age 19, Height 187 cm: Weight 73 kg (BMI = 20.9). BP = 118/70, HR 86,
RR 22, temperature 37.0 C, SaO2 99% on room air.
Eating habits (nutrition/diet): The patient is not good in the kitchen, so he used to eat rice, bread, and meat and rarely

eat vegetables in a meal (Panahi, Ghanei, Hajhashemi & Sahebkar, 2016). (1 mark)