Subject: General Questions / General General Questions
Question
Course Project Milestone 1:Health History
Guidelines and Grading Rubric
PURPOSE
The student will obtain a health history on a willing, nonrelated, adult participant in order to generate written documentation that is clear and accurate.
COURSE OUTCOMES
This assignment enables the student to meet the following Course Outcomes.
CO #3: Utilize effective communication when performing a health assessment. (PO #3)
CO #4: Identify teaching/learning needs from the health history of an individual. (PO #2)
CO #5: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO #6)
POINTS
This assignment is worth a total of 200 points.
DUE DATE
The Course Project Milestone 1: Health History assignment is to be submitted to the Dropbox by Sunday, 11:59 p.m. MT at the end of Week 4. The guidelines and grading rubric may be found in Doc Sharing. Post questions to the Q&A Forum. Contact your instructor if you need additional assistance.
DISCLAIMER
The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do not need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.”If the client fails to disclose answers to several items, you will need to find another client who is willing to share.
DIRECTIONS
1. Find an adult who is not related to you who is willing to let you take a health history.
2. Download the NR305_Milestone1_Form from Doc Sharing. You will type your answers directly into this Word document. Your paper does not need to follow APA formatting; however, you are expected to be clear in your communication by using correct medical terminology, grammar, and spelling.
3. Review the examples in Chapter 4 of your textbook to gain insight into how to document the health history.Remember this is a health history, not a physical examination. Avoid words like frequently, improved, increased, decreased, good, poor, normal, or WNL as they may have different meanings for different people. Instead, document the specific data that led you to these conclusions, for example, 3x/day instead of frequently, or consuming four servings of vegetables/day instead of increased vegetable servings.
4. Save the file by clicking Save as and adding your last name to the file name, for example, NR305_Milestone1_Form_Smith.
5. Submit the completed form to the Dropbox by Sunday, 11:59 p.m. MT at the end of Week 4.
6. Please post questions in the weekly Q&A Forumsso the entire class may view the answers.
Course Project Milestone #1: Health History Form
Your Name: Date:
Your Instructor’s Name:
Directions: Refer to the Milestone 1: Health History guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 200 points, with 10 points awarded for clarity of writing, which means the use of proper grammar, spelling, and medical language.
Type your answers on this form. Click Save as and save the file with the assignment name and your last name, for example, NR305_Milestone1_Form_Smith. When you are finished, submit the form to the Milestone #1 Dropbox by the deadline indicated in your guidelines. Post questions in the Q&A Forum or contact your instructor if you have questions about this assignment.
Disclaimer:The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do not need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.”If the client fails to disclose answers to several items, you will need to find another client who is willing to share.
BIOGRAPHICAL DATA (10 points)
Date:
Initials:
Age:
Date of birth:
Birthplace:
Gender:
Marital status:
Race:
Religion:
Occupation:
Health insurance:
Source of information:
Reliability of source of information:
PRESENT HEALTH HISTORY/ILLNESS (20 points)
Reason for seeking care:
Health patterns:
Health goals:
HEALTH BELIEFS AND PRACTICES (15 points)
Beliefs and practices:
Factors influencing healthcare decisions:
Related traits, habits or acts:
MEDICATIONS (20 points) (Please refer to your assignment guidelines.)
Prescription medications:
Over-the-counter medications:
Herbals:
PAST HISTORY (20 points)
Childhood diseases:
Immunizations:
Allergies:
Blood transfusions:
Major illnesses:
Injuries:
Hospitalizations:
Labor and deliveries:
Surgeries:
Use of alcohol:
Use of tobacco:
Use of illicit drugs:
EMOTIONAL HISTORY (15 points)
Mental, emotional or psychiatric problems:
FAMILY HISTORY (20 points)
Father:
Mother:
Siblings:
Grandparents:
PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 points)
Occupational history:
Educational level:
Financial background:
ROLES AND RELATIONSHIPS (15 points)
Significant others:
Support systems:
ETHNICITY AND CULTURE (10 points)
Ethnicity and culture:
Physical and social characteristics that influence healthcare decisions:
SPIRITUALITY (5 points)
Religious and spiritual needs:
SELF-CONCEPT (5 points)
View of self-worth:
Future plans:
REVIEW OF SYSTEMS (20 points) (Please refer to your assignment guidelines and Chapter 4 of your text. This is not a physical examination.)
Skin, hair, nails:
Head, neck, related lymphatics:
Eyes:
Ears, nose, mouth, and throat:
Respiratory:
Breasts and axillae:
Cardiovascular:
Peripheral vascular:
Abdomen:
Urinary:
Reproductive:
Musculoskeletal:
Neurologic:
