Initial History and Physical Assessment Form
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Christiana Care Health Services
Wilmington,
Delaware,
USA
For all new patients in the HIV program, the nurse will complete the first three pages of this form during the patient’s initial visit to the clinic. The doctor/nurse practitioner who performed the patient’s physical assessment will then finalize the form.
The initial nurse interview session and doctor/nurse practitioner visit include the following:
- Counsel and educate regarding HIV disease process
- Explain the HIV program structure
- Complete the Initial History and Physical Assessment Form
Background
This form was developed several years ago as a comprehensive and consistent nursing assessment tool and as a way to insure that information needed for the CARE Act yearly reports was collected in a standard fashion.
Both nursing and medical staff contributed to the development of this form. This form is currently used by all sites of the Christiana Care Health System HIV Program and is adapted as necessary to reflect current guidelines in HIV care.
Directions
During the patient's initial visit to the clinic, the nurse completes the "Initial Nurse Interview" section on the first three pages of the form. At this point, the patient is sent for baseline labs and x-ray and scheduled for an initial doctor/nurse practitioner visit. When the patient returns for their scheduled visit, the doctor/nurse practitioner who performs the initial examination completes the form.
Related Changes
Decision Support
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