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 175 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 this 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.
DirectionsFind an adult who is not related to you who is willing to let you take a health history.
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.
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 assessment. 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 e.g. 3x/day instead of frequently or consuming 4 servings of vegetables/day instead of increased vegetable servings.
Save the file by clicking Save as and adding your last name to the file name e.g. NR305_Milestone1_Form_Smith.
Submit the completed form to the Dropbox by Sunday 11:59 p.m. MT at the end of Week 4. Please post questions in the weekly Q & A Forums so the entire class may view the answers.Grading CriteriaCategory
Points
%
DescriptionBiographical Data
10
6
Date of health history clients initials age date of birth birthplace gender marital status race religion occupation health insurance information source of information and the reliability of the source. Do NOT include identifying information such as phone numbers address etc.Present Health History/ Illness
15
9
Reasons for seeking care health patterns and health goals.Health Beliefs and Practices
15
9
Health beliefs and practices including factors that influence their healthcare decisions related traits habits or acts that affect a clients health.Medications
15
9
Use of prescription medications over-the-counter medications and/or any herbals. Include name dose purpose duration frequency and desired or undesired effects of each of the medications.Past History
15
9
Childhood diseases immunizations allergies blood transfusions major illnesses injuries hospitalizations labor and deliveries surgeries and use of alcohol tobacco and illicit drugs.Emotional History
15
9
Includes information about any mental emotional or psychiatric health problems.Family History
15
9
Review of health history of the father mother sibling(s) and grandparents to determine if any genetic or familial patterns of health or illness might affect current health status.Psychosocial/ Occupational History
15
9
Includes information about occupational history educational level and financial background.Roles and Relationships
15
9
Information about the clients roles and relationships; including identifying a significant other and support systems (friends neighbors club members clergy church members and members of the healthcare team)Ethnicity and Culture
10
6
Clients ethnicity and culture and physical and social characteristics that influence healthcare decisions.Spirituality
5
3
Clients religious and spiritual needs. (Spirituality refers to the individuals sense of self in relation to others and a higher being.)Self-Concept
5
3
Includes information on how they view their self-worth and plans for the future.Review of Systems
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20
12
Focus is to uncover current and past information about each body system and its organs. Ask about the system function and any abnormal signs or symptoms paying attention to gathering information about the functional patterns of each system. Clarity of Writing
5
3
Content is organized logically and clearly understandable. Documentation is clear and accurate. Words like frequently improved increased and decreased not used instead provide specific examples.Total
175 pts
100%
A quality paper will meet or exceed all of the above requirements.Grading RubricAssignment Criteria
A
Outstanding or highest level of performance
B
Very good or high level of performance
C
Competent or satisfactory level of performance
F
Poor or failing or unsatisfactory level of performanceBiographical Data
(10 points)
All required criteria included. No errors.
(10 points)
No more than one required elements missing
(89 points)
More than two required elements missing.
(67 points)
Three or more required elements missing.
(05 points)Present Health History/Illness
(15 points)
All required criteria included. No errors.
(1315 points)
One required element missing
(1112 points)
Two required elements missing.
(910 points)
Required elements missing.
(08 points)Health Beliefs and Practices
(15 points)
All required criteria included. No errors.
(1315 points)
One required elements missing
(1112 points)
Two required elements missing.
(910 points)
Required elements missing.
(08 points)Medications
(15 points)
All required criteria included. No errors.
(1315 points)
One required elements missing
(1112 points)
Two required elements missing.
(910 points)
Required elements missing.
(08 points)Past History
(15 points)
All required criteria included. No errors.
(1315 points)
One required elements missing
(1112 points)
Two required elements missing.
(910 points)
Required elements missing.
(08 points)Emotional History
(15 points)
All required criteria included. No errors.
(1315 points)
One required element missing
(1112 points)
Two required elements missing
(910 points)
Required elements missing
(08 points)Family History
(15 points)
All required criteria included. No errors.
(1315 points)
One required element missing
(1112 points)
Two required elements missing
(910 points)
Required elements missing
(08 points)Psychosocial/ Occupational History
(15 points)
All required criteria included. No errors.
(1315 points)
One required element missing
(1112 points)
Two required elements missing
(910 points)
Required elements missing
(08 points)Roles and Relationships
(15 points)
All required criteria included. No errors.
(1315 points)
One required element missing
(1112 points)
Two required elements missing
(910 points)
Required elements missing
(08 points)Ethnicity and Culture
(10 points)
All required criteria included. No errors.
(10 points)
No more than one required elements missing
(89 points)
More than two required elements missing
(67 points)
Required elements missing
(05 points)Spirituality
(5 points)
All required criteria included. No errors.
(5 points)
No more than one required elements missing
(4 points)
More than two required elements missing
(3 points)
Required elements missing
(02 points)Self-Concept
(5 points)
All required criteria included. No errors.
(5 points)
No more than one required elements missing
(4 points)
More than two required elements missing
(3 points)
Required elements missing
(02 points)Review of Systems
(20 points)
All required criteria included. No errors.
(1820 points)
Two to three required elements missing. Did not include information about functional patterns of each system.
(1617 points)
Three required elements missing. Total body systems and/or functional patterns missing.
(1415 points)
Greater than three required elements missing. Total body systems and/or functional patterns missing.
(013 points)Clarity of Writing
(5 points)
Organized logically and written clearly with good structure
(5 points)
Lacks some organization & clarity. Uses words such as frequently increased decreased.
(4 points)
Lacks logical organization; difficult to read. Uses words such as frequently increased decreased.
(3 points)
Lacks logical organization; difficult to read. Many spelling errors.
(02 points)Total Points Possible = 175 points
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