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Assessment data that would be helpful for the nurse practitioner to have include physical exam, mental health history, current medications, lab results, vital signs, imaging studies (e.g., X-rays), and any other diagnostic studies (e.g., computed tomography [CT] scans) that may have been performed by a specialist. Additionally, reports from other providers involved in the patient’s care such as primary care physician visits or specialist visits can provide additional insight into the patient’s condition and treatment plan.
The patient’s social history is important in order to gain an understanding of potential stressors or changes in their environment which could affect their overall health. For example, family dynamics and support structures can help to explain why certain behaviors are occurring and how to appropriately address them. Furthermore, information regarding employment status and recreational activities can also provide insight into potential causes of distress or areas where lifestyle modifications might improve outcomes for the patient.
Environmental factors should also be taken into consideration when assessing a patient’s condition due to a possible correlation between environmental exposures and disease development/progression. Questions related to housing conditions, exposure to hazardous materials at home or work sites may help inform decisions regarding further testing or management interventions if necessary.
Finally it is helpful for practitioners who are seeing a new patient for the first time to review any past medical records they may have available as this will give them an overview of what treatments/interventions were tried previously and what was successful/unsuccessful at addressing the symptoms presented by the individual prior to their current visit with you. This helps ensure continuity of care while avoiding redundant tests/treatments that have already been unsuccessful with this particular individual.