| Course | D222 Comprehensive Health Assessment |
|---|---|
| Task | Task 1 |
| Paper type | Comprehensive health assessment documentation |
| Length | About 1,100 words, 5 pages |
| Format | APA 7 |
| School | Western Governors University (WGU) |
| Program | RN to BSN |
| Updated | September 2026 |
Free sample paper for D222 Task 1
Comprehensive Health Assessment Documentation: A 39-Year-Old Woman Who Runs a Licensed Home Daycare
Student Name
Leavitt School of Health, Western Governors University
D222: Comprehensive Health Assessment, Task 1
Course Instructor
Month Day, Year
Comprehensive Health Assessment Documentation: A 39-Year-Old Woman Who Runs a Licensed Home Daycare
Identifying Data and Reason for Assessment
The patient is a composite 39-year-old woman who owns and runs a licensed home daycare for six children aged 1 to 5. She is a reliable historian and consented to a comprehensive wellness assessment. She has no acute complaint but reports feeling 'tired all the time' for about four months. Her last visit to a primary care provider was three years ago.
Health History
Present health: fatigue for four months, worse by mid-afternoon, not relieved by weekend rest. Menstrual periods have become heavier over the past year, lasting seven days, with two days of soaking a pad every two hours. She reports low back ache at the end of most days from lifting toddlers. She denies fever, weight loss, night sweats, chest pain and shortness of breath at rest.
Past medical history: two uncomplicated vaginal births at ages 29 and 32. No chronic illnesses, surgeries or hospitalizations. Medications: ibuprofen 400 mg taken on two or three days each week for back ache; a daily multivitamin. No known drug allergies; seasonal allergic rhinitis. Immunizations: childhood series complete by report, tetanus booster at age 32, influenza vaccine each fall because daycare licensing requires it. Cervical screening: last Pap test five years ago, normal.
Family history: mother, 64, type 2 diabetes and hypertension; father, 67, hyperlipidemia; maternal aunt with breast cancer at 58. Two children, 10 and 7, healthy.
Review of Systems
General: fatigue as above; weight stable at about 159 pounds. Skin: no rashes or changing moles; nails brittle. Head, eyes, ears, nose and throat: occasional tension headaches, no vision change, no hearing loss, seasonal congestion. Cardiovascular: no palpitations, chest pain or edema. Respiratory: no cough or wheeze. Gastrointestinal: good appetite, no nausea, no change in bowel habits, no dark or bloody stools. Genitourinary: heavy menses as above, no dysuria. Musculoskeletal: low back ache without radiation, numbness or weakness. Neurological: no dizziness, weakness or tingling. Endocrine: no heat or cold intolerance, no increased thirst. Hematologic: bruises easily on shins. Sleep: six hours on weeknights, wakes unrefreshed.
Physical Examination
General survey: alert, well groomed, appropriately dressed, speech clear, appears slightly tired. Vital signs: blood pressure 128/82 mm Hg right arm seated after five minutes rest, 126/80 on repeat; pulse 92 beats per minute, regular; 16 breaths per minute; oral temperature 36.7 C; oxygen saturation 98% on room air. Height 165 cm, weight 72 kg, body mass index 26.4, waist circumference 86 cm. Pain 3 of 10 in the low back at rest.
Integument: warm, dry and pale overall; three small ecchymoses on the anterior shins at different stages of healing; nails thin and brittle without clubbing; hair evenly distributed. Head and neck: normocephalic, no lesions; thyroid smooth and nontender without nodules; no cervical lymphadenopathy. Eyes: pupils equal, round and reactive to light and accommodation; extraocular movements intact; palpebral conjunctivae pale. Ears: tympanic membranes pearly gray with visible landmarks bilaterally. Nose and throat: nasal mucosa pale and boggy; oral mucosa moist; two posterior molars with visible caries; tongue smooth at the edges.
Chest and lungs: thorax symmetric, expansion equal on both sides; resonant to percussion; breath sounds vesicular throughout without crackles or wheezes. Heart: S1 and S2 regular; a faint, grade 1/6 early systolic flow murmur heard best at the left upper sternal border without radiation; no gallops; capillary refill under 2 seconds; radial and dorsalis pedis pulses 2+ and equal. Abdomen: flat contour, active bowel sounds heard in each quadrant, soft and nontender, no organomegaly on palpation. Musculoskeletal: full range of motion of all joints; mild tenderness over the lumbar paraspinal muscles bilaterally; straight leg raise negative bilaterally; strength 5 of 5 throughout. Neurological: oriented to person, place, time and situation; cranial nerves II to XII grossly intact; sensation intact to light touch; gait steady; Romberg negative.
Mental and Emotional Health
She describes her mood as 'fine but stretched thin.' On the Patient Health Questionnaire-2 she scored 1 of 6, below the usual cutoff of 3 for further depression screening (Kroenke et al., 2003). On the Generalized Anxiety Disorder 2-item screen she scored 3 of 6, which meets the threshold at which a fuller anxiety assessment is recommended (Kroenke et al., 2007). She reports worrying about money and about coping if a child in her care were injured. She denies thoughts of self-harm. Affect is congruent and she is engaged throughout the assessment.
Spiritual and Cultural Assessment
She was born in the United States to parents who emigrated from Vietnam and speaks English and Vietnamese at home. She identifies as Buddhist and visits a temple with her parents on major holidays; she says meditation helped her after her second child was born but she has not practiced it for years. She prefers to see a woman for gynecological care. Her family places high value on caring for others before oneself, and she notes that her mother 'never went to the doctor unless something was broken,' which she recognizes in her own habits. She eats a mixed diet of Vietnamese home cooking and quick meals during the workday, with little red meat.
Social Determinants of Health
She and her husband, who works nights in a warehouse, own a small house in a suburban neighborhood with sidewalks and a park nearby. The family buys health insurance through the marketplace with a high deductible, and she has delayed visits because of cost. She works 11-hour days, five days a week, without paid sick time or a substitute caregiver. Food security is adequate. She drives, has reliable transportation and has completed two years of community college. Social support comes from her parents, who live 20 minutes away.
Summary of Findings
This is a generally healthy 39-year-old woman whose assessment points to four areas that need attention. Fatigue with heavy menstrual bleeding, pallor, pale conjunctivae, brittle nails, easy bruising, a mildly elevated resting heart rate and a soft flow murmur together suggest possible iron deficiency anemia, which calls for referral for a complete blood count and iron studies. A positive anxiety screen in the context of long work hours and financial stress needs further assessment. Recurrent mechanical low back pain is linked to lifting at work. Preventive care is overdue: cervical screening is past its interval and dental caries are untreated. Cost, the lack of a substitute caregiver and a family habit of putting others first are the main barriers to acting on these findings, and they will shape the health promotion activities recommended from this assessment. Documentation follows the head-to-toe sequence and techniques described in a standard examination text (Bickley et al., 2021).
References
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2003). The Patient Health Questionnaire-2: Validity of a two-item depression screener. Medical Care, 41(11), 1284-1292. https://doi.org/10.1097/01.MLR.0000093487.78664.3C
Kroenke, K., Spitzer, R. L., Williams, J. B. W., Monahan, P. O., & Löwe, B. (2007). Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine, 146(5), 317-325. https://doi.org/10.7326/0003-4819-146-5-200703060-00004
What the D222 Task 1 instructions ask
The first D222 task asks you to complete and document a comprehensive health assessment of one adult. Most versions list the parts: identifying data, history, systems review, head-to-toe examination, mental and emotional screening, a spiritual and cultural assessment, social determinants of health and a summary of findings. You usually assess a volunteer, often a friend or family member, with consent, and remove identifying details. The documentation should read like a clinical record: organized, specific and complete, including normal findings. The summary is where analysis happens, since it must pull the findings that matter from a large amount of data.
How this D222 Task 1 example is built
The documentation follows the order of a clinical record, starting with identifying data and the reason for assessment. The history records present health in concrete terms, such as the pattern and duration of fatigue. The review of systems goes system by system, including negatives. The physical examination opens with a general survey and vital signs, then documents each system, with normal findings recorded as precisely as abnormal ones. Screening tools are named and scored with their cutoffs. The spiritual, cultural and social sections describe the patient's own practices and resources. The summary groups the findings into four areas that need attention, which sets up the health promotion plan in Task 2.
Where the D222 Task 1 rubric puts the marks
The D222 Task 1 rubric checks each component on the scale of competent, approaching competence or not evident. Evaluators look for completeness first: every required section present and filled with specific data. Physical examination aspects check that findings are documented accurately in clinical terms, including normal ones. Screening aspects look for named tools with scores and interpretation. Cultural, spiritual and social determinant aspects ask for patient-specific detail rather than general statements about groups. The summary aspect rewards synthesis that identifies priorities from the data. Professional documentation style, with correct terminology and APA citation of any tools used, is part of the scoring. Evaluators notice when abnormal and normal findings are recorded with equal care, since that is how clinical documentation is judged in real practice settings.
D222 Task 1 help: what sends it back
The most common problem is incomplete normal findings. Writing normal for a system gives the evaluator nothing to check; document what you inspected, palpated or heard. Second, cultural assessments often describe a group rather than the person. Ask the patient about her own beliefs and practices. Third, screening tools are mentioned without scores or cutoffs. Record the result and what it means. Fourth, the summary tends to repeat the whole assessment. Select the findings that need follow-up and explain why. Finally, protect the volunteer's privacy by removing names, exact dates and anything identifying, since a documentation task is still a record about a real person.
Get a D222 Task 1 example written to your instructions
Send the Task 1 instructions, template and rubric from your D222 course of study. We write a custom documentation example to those exact aspects, using a composite patient, and return it in 24-48h. The first custom sample is free.
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D222 Task 1 questions, answered
Who can I assess for D222?
Your instructions set the rules. In current versions the patient must be an adult with the capacity to take part and consent to being recorded, and many students assess a family member or friend. Keep identifying details out of the written documentation, and follow the course's consent and privacy requirements for the recording exactly.
How detailed should normal findings be in D222 documentation?
Detailed enough to show what you did. 'Lungs clear to auscultation bilaterally in all lobes, no adventitious sounds, respirations even and unlabored' shows an assessment; 'lungs normal' does not. Use the terms from the skills list, and record pertinent negatives in the history as well as the examination.
Does the summary need to lead into health promotion?
Yes, in current versions it does. The health promotion activities you recommend have to be justified by what you found, so the summary should name the findings that point toward them, such as elevated blood pressure, a positive screen or a gap in preventive care.
How long does a D222 comprehensive assessment usually take?
Plan for about an hour with your volunteer to cover the history, review of systems, examination and screenings, then extra time to write documentation that includes normal findings system by system.
Where can I find a free D222 Task 1 sample paper?
Every section of the documentation, from identifying data to the summary, is above with comments. Send the D222 instructions and your volunteer's findings for a first custom version at no cost.