Professional Communication Health Assessment Clinical Note

This assignment is a health assessment clinical note completed by a nursing student. It details an interview with a 43-year-old patient, Helen Henderson, focusing on her health concerns, lifestyle, and habits. The note includes a situation analysis, background information on her health history and family relationships, and an assessment of her physical and mental health. The assessment covers her weight, eating habits, alcohol consumption, and exercise routine. Recommendations are provided, suggesting increased exercise, reduced work hours, and more family time. The note also includes subjective patient progress notes, a review of systems, assessment, and a plan for the patient's care. The student registered nurse signs off on the documentation, which is worth 10 marks and includes the marker's name and signature.

401205 Professional Communication in Nursing
Health Assessment Clinical Note
StudentNumber: StudentName:
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: Helen Henderson Dateofbirth: 24/05/1976 Address: 48 Villahome Drive, Southwood,
2074
Situation
Reasons for assessment, allergies, and relevant personal details: Helen is a 43 year old women, married to
Janine. She is suffering from psychological concern, fatigue, and tiredness. She does not have any allergic
condition and she works long hours for financial concern of her family. She consumed healthy food and 2 to
3 glasses champagne in weekends.
Background
(1 mark)
Health history, general health and psychosocial status: Helen’s health conditions are associated with
her mental health condition. She is suffering from psychological conditions and tiredness. She is conscious
of her diet, her skin and due to which she tries to consume healthy diet.
Living arrangements and family relationships: she is married to her friend Janine. She is close to her family
members however due to long working hours and work commitments she is unable to meet them.
Assessmen
t
(1 mark)
Observations, height, weight (shape): her weight is around 94 kg, height 175 cm, and hence it could be
understood that she is obese.
Eating habits (nutrition/diet): she is unable to make or cook food and she is dependent on the takeaways.
Further, despite of choosing healthy foods like sushi, and salads, she consumes hamburger or chips
sometimes. (1 mark)

Assessment (cont’d...)
Alcohol (frequency, amount): she does not consume alcohol however, enjoys a 2-3 glasses of champagne
over the weekend.
(0.5Mark)
Cigarettes(frequency, duration): she does not smoke
(0.5Mark)
daily activities/exercise/amount of physical activity (type, frequency, time): her only exercise is the concern
is the 10 minutes of walk to reach to her office.
Describe: Community-Social/cultural/spiritual (or religious): It was seen that she is religious and goes to mass at
her local Catholic Church whenever she can
Recommendation
(1 mark)
She should increase her exercise timings and should focus on moderate to high body weight and weight training
exercises so that her obesity could be prevented. Further, it should be mentioned that she should decrease her work
timings and should focus on her family concerns and spend time with her family members.
Patient Progress Notes Date:
(1 mark)
Time:
Subjective: Ms. Helen Henderson was assessed previously on (mention date) her general healthcare
assessment revealed that she is suffering from obesity due to which she is feeling tiredness and fatigue in her
everyday life.
Review of system: she does not have any past allergy or health complication
Assessment: she is suffering from psychological concerns.
Plan: it was recommended to the patient that she should start spending time with her family and reduce her long
working hours so that she could overcome her health condition. Further, she was asked to perform exercise and
moderate to high weight and body weight exercise so that she could improve her obesity condition and reduce the risk
related to obesity.
Signature: Name: Student RegisteredNurse
(4 marks)
(AddtoRubricMark-TaskPerformanceCriteriaDocumentation) SubtotalMark: /10
Marker’sName: Signature: Date: