Health History Guidelines: Patient Assessment

Download and review the Health History Guidelines. (Links to an external site.)
Submit the assignment as directed by your instructor.
See Calendar for due date information.
Rubric
NR302 RUA: Health History Guidelines 
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeHealth History Assessment
Required criteria
1. Demographics
2. Perception of Health
3. Past Medical History
4. Family Medical History
5. Review of Systems
6. Developmental Considerations
7. Cultural Considerations
8. Psychosocial Considerations
9. Collaborative Resources
70 pts
Highest Level of Performance
Includes 9 requirements for section.
66 pts
High Level of Performance
Includes 7-8 requirements for section.
52 pts
Satisfactory Performance
Includes 5-6 requirements for section.
35 pts
Unsatisfactory Performance
Includes 1-4 requirements for section.
0 pts
Not Present
No requirements for this section presented.
70 pts
This criterion is linked to a Learning OutcomeReflection
Required criteria
1. Reflect on your interaction with the interviewee holistically.
a) Describe the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process.
2. How did your interaction compare to what you have learned?
3. What barriers to communication did you experience?
a) How did you overcome them?
b) What will you do to overcome them in the future?
4. What went well with this assignment?
5. Were there unanticipated challenges during this assignment?
6. Was there information you wished you had available but did not?
7. How will you alter your approach next time?
20 pts
Highest Level of Performance
Includes 7 requirements for section.
18 pts
High Level of Performance
Includes 6 requirements for section.
16 pts
Satisfactory Performance
Includes 5 requirements for section.
10 pts
Unsatisfactory Performance
Includes 1-4 requirements for section.
0 pts
Not Present
No requirements for this section presented.
20 pts
This criterion is linked to a Learning OutcomeStyle and Organization
Required criteria
1. Grammar and mechanics are free of errors.
2. Verbalizes thoughts and reasoning clearly.
3. Uses appropriate resources and ideas to support topic with APA where applicable.
10 pts
High Level of Performance
Includes no fewer than 3 requirements for section.
8 pts
Satisfactory Performance
Includes no fewer than 2 requirements for section.
4 pts
Unsatisfactory Performance
Includes 1 requirement for section.
0 pts
Not Present
No requirements for this section presented.
10 pts
Total Points: 100
RUA: Health History Guidelines
NR302_Health_History_Guidelines_V7 Revised:Mar/22 1
Purpose
Before any nursing plan of care or intervention can be implemented or evaluated, the nurse assesses the individual through the collection of both subjective and objective data. The data collected are used to determine areas of need or problems to be addressed by the nursing care plan. This assignment will focus on collecting subjective assessment data, synthesizing the data, and on identifying health/wellness priorities based on the findings. The purpose of the assignment is two-fold:
• To recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual, and developmental) affecting health and wellness.
• To reflect on the interactive process between self and client when conducting a health assessment.
Course Outcomes: This assignment enables the student to meet the following course outcomes:
CO 1: Explain expected client behaviors while differentiating between normal findings variations, and abnormalities. (PO 1)
CO 2: Utilize prior knowledge of theories and principles of nursing and related disciplines to integrate clinical judgment in professional decision-making and implementation of nursing process while obtaining a physical assessment. (POs 4 & 8)
CO 3: Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1)
CO 4: Utilize effective communication when performing a health assessment. (PO 3)
CO 5: Demonstrate beginning skill in performing a complete physical examination, using the techniques of inspection, palpation, percussion, and auscultation. (PO 2)
CO 6: Identify teaching/learning needs from the health history of an individual. (POs 2 & 5)
CO 7: Explore the professional responsibility involved in conducting a comprehensive health assessment and providing
appropriate documentation. (POs 6 & 7)
Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to
this assignment.
Total points possible: 100 points
Preparing the assignment
Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.
1. Complete a health assessment/history on an individual of your choice who is 18 years of age or older and NOT a family member or close friend.
a. The purpose of this restriction is to avoid any tendency to anticipate answers or to influence how the questions are answered. Your goal in choosing an interviewee is to simulate the interaction between you and an individual for whom you would provide care.
b. Inform the individual that information obtained will be kept confidential and do not use identifying information
within the assignment.
c. There are three parts to this assignment.
2. Include the following sections when completing the assignment
a. Health History Assessment (50 points/50%)
1) Demographics
2) Perception of Health
3) Past Medical History
4) Family Medical History
5) Review of Systems
6) Developmental Considerations- use Erikson’s Stages of Psychosocial Development- which stage is your participant at and give examples of if they have met or not met the milestones for that stage.
7) Cultural Considerations- definition, cultural traditions, cultural viewpoints on healing/healers, traditional and complementary medicine, these are examples but please add more
8) Psychosocial Considerations-supportsystems-family, religious, occupational, community these are examples but please add more
9) Resources to Improve Health- give examples of resources available to improve the health of the participant such as community, nutritional recommendations, healthcare, spiritual, etc.
b. Reflection (40 points/40%)
Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to evaluate outcomes. Provide a written reflection that describes your experience with conducting this Health
History.
1) Reflect on your interaction with the interviewee holistically.
a) Describes the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process.
2) How did your interaction compare to what you have learned?
3) What barriers to communication did you experience?
a) How did you overcome them?
b) What will you do to overcome them in the future?
4) What went well with this assignment?
5) Were there unanticipated challenges during this assignment?
6) Was there information you wished you had available but did not?
7) How will you alter your approach next time?
3. Style and Organization (10 Points/10%)
Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired information, and appropriate writing skills. Scoring of your work in written communication is based on proper use of grammar, spelling, APA, and how clearly you express your thoughts and reasoning in your writing.
1) Grammar and mechanics are free of errors.
2) Verbalizes thoughts and reasoning clearly
3) Uses appropriate resources and ideas to support topic with APA where applicable.
For writing assistance, visit the Writing Center.
Please note that your instructor may provide you with additional assessments in any form to determine that you fully understand the concepts learned in the review module.
3) Past Medical History
4) Family Medical History
5) Review of Systems
6) Developmental Considerations- use Erikson’s Stages of Psychosocial Development- which stage is your participant at and give examples of if they have met or not met the milestones for that stage.
7) Cultural Considerations- definition, cultural traditions, cultural viewpoints on healing/healers, traditional and complementary medicine, these are examples but please add more
8) Psychosocial Considerations-supportsystems-family, religious, occupational, community these are examples but please add more
9) Resources to Improve Health- give examples of resources available to improve the health of the participant such as community, nutritional recommendations, healthcare, spiritual, etc.
b. Reflection (40 points/40%)
Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to evaluate outcomes. Provide a written reflection that describes your experience with conducting this Health
History.
1) Reflect on your interaction with the interviewee holistically.
a) Describes the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process.
2) How did your interaction compare to what you have learned?
3) What barriers to communication did you experience?
a) How did you overcome them?
b) What will you do to overcome them in the future?
4) What went well with this assignment?
5) Were there unanticipated challenges during this assignment?
6) Was there information you wished you had available but did not?
7) How will you alter your approach next time?
3. Style and Organization (10 Points/10%)
Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired information, and appropriate writing skills. Scoring of your work in written communication is based on proper use of grammar, spelling, APA, and how clearly you express your thoughts and reasoning in your writing.
1) Grammar and mechanics are free of errors.
2) Verbalizes thoughts and reasoning clearly
3) Uses appropriate resources and ideas to support topic with APA where applicable.
For writing assistance, visit the Writing Center.
Please note that your instructor may provide you with additional assessments in any form to determine that you fully
understand the concepts learned in the review module.
3) Past Medical History
4) Family Medical History
5) Review of Systems
6) Developmental Considerations- use Erikson’s Stages of Psychosocial Development- which stage is your participant at and give examples of if they have met or not met the milestones for that stage.
7) Cultural Considerations- definition, cultural traditions, cultural viewpoints on healing/healers, traditional and complementary medicine, these are examples but please add more
8) Psychosocial Considerations-supportsystems-family, religious, occupational, community these are examples but please add more
9) Resources to Improve Health- give examples of resources available to improve the health of the participant such as community, nutritional recommendations, healthcare, spiritual, etc.
b. Reflection (40 points/40%)
Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to evaluate outcomes. Provide a written reflection that describes your experience with conducting this Health
History.
1) Reflect on your interaction with the interviewee holistically.
a) Describes the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process.
2) How did your interaction compare to what you have learned?
3) What barriers to communication did you experience?
a) How did you overcome them?
b) What will you do to overcome them in the future?
4) What went well with this assignment?
5) Were there unanticipated challenges during this assignment?
6) Was there information you wished you had available but did not?
7) How will you alter your approach next time?
3. Style and Organization (10 Points/10%)
Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired information,
and appropriate writing skills. Scoring of your work in written communication is based on proper use of
grammar, spelling, APA, and how clearly you express your thoughts and reasoning in your writing.
1) Grammar and mechanics are free of errors.
2) Verbalizes thoughts and reasoning clearly
3) Uses appropriate resources and ideas to support topic with APA where applicable.
For writing assistance, visit the Writing Center.
Please note that your instructor may provide you with additional assessments in any form to determine that you fully
understand the concepts learned in the review module.
Criteria are met when the student’s application of knowledge within the paper demonstrates achievement of the outcomes for this assignment.
Assignment Section and
Required Criteria
(Points possible/% of total points available)
Highest Level of
Performance
High Level of
Performance
Satisfactory
Level of
Performance
Unsatisfactory
Level of
Performance
Section not
present in
paper
Health History Assessment
(70 points/70%) 70 points 66 points 52 points 35 points 0 points
Required criteria
1. Demographics
2. Perception of Health
3. Past Medical History
4. Family Medical History
5. Review of Systems
6. Developmental Considerations
7. Cultural Considerations
8. Psychosocial Considerations
9. Collaborative Resources