NR 305 Assignment Course Project Milestone 1: Health History Guidelines
NR 305 Assignment Course Project Milestone 1: Health History Guidelines
Updated 9/22/2017
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. Note: Failing to complete this
assignment using an adult participant other than yourself will result in a 20%
penalty deduction being applied.
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 225 points.
Due Date
The Course Project Milestone 1: Health History
assignment is to be submitted by Sunday, 11:59 p.m. MT at the end of Week 4.
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
Find an adult who is not related to you who is
willing to let you take a health history.
Download the NR305_Milestone1_Form (Links to an
external site.)Links to an external site.. 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.
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.
Course Project Milestone #1: Health
History Form
Your Name: Date:
Your Instructors Name:
Directions:
Refer to the Milestone 1: Health History guidelines and grading rubric found on
the Week 1: Milestone 1 Assignment page. This assignment is worth 225 points.
Clarity of writing is worth 20 of the 225 points.
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 by the
deadline by using the Submit button on the assignment page. 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.
Note: Completing this assignment on yourself will result in
a 20% penalty deduction being applied.
| BIOGRAPHICAL DATA (15 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 (15 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 (25 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: |
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