Accomplishing Health History Form

Health history

Health History  Guidelines and Grading Rubric
Purpose

The student will obtain a health history from a nonrelated adult participant in order to demonstrate effective communication and scholarly written communication.Course Outcomes1. Examine communication patterns used in the care of culturally diverse individuals and families (PO 1) 7. Integrate professional awareness of the effect of genetics, culture and healthcare disparities on the health of individuals and families. (PO 9) 8. Demonstrate scholarly written communication supported by current evidence (PO-9)  
Points
This assignment is worth 20% of your course grade or 200 points. Due Date
The assignment Health History is due on Sunday by 11:55 pm ET at the end of week 4.  The guidelines and grading rubric may be found under the assignments tab in your course.
Disclaimer
It is important to recognize an individual’s right to privacy.  While it is essential that the information that you collect be accurate, be sure to notify your participant at any point in time they can choose to not share information with you.  If they choose not to share information please write in the respective area “Does not want to disclose”.
Directions 1. Find an adult who is not related to you and willing to participate to obtain a health history.2. You may use the form below to gather your data. This information can be cut and pasted into a word document so that the responses you obtain are typed. This assignment does not require APA format except for a title page.  It is expected that the student will use correct medical terminology and proper grammar, syntax, and spelling.3. Review Chapter 4 in your textbook to review how to document a health history.  Remember you are not completing a physical assessment.  Therefore, you should avoid qualifier terms such as WNL, frequently or normal.  These are not measureable terms. 4. Submit the assignment under the assignment tab by Sunday at the end of week 4 prior to 11:55 pm ET.

Grading Criteria

Criteria Points % NarrativeBiographical Data 15 1.5 Demographic information  including date of health history, client’s age, date of birth, gender, birthplace, marital status, race, religion, occupation, and reliability of the information obtained.Present Health History/Illnesses 15 1.5 When do they seek health care, what is their health status at this time and what are their health goals.Health Beliefs and Practices 15 1.5 Health beliefs and practices – consider here factors that can influence health – exercise, alcohol/drug use, how do they get to work, do they wear a seat beltMedications 15 1.5 Use of prescription medications, over-the-counter medications and herbal supplements. Include name, dose, purpose, frequency and any positive/negative effects from each medicationPast Health History 15 1.5 Childhood diseases, immunizations, allergies, major illnesses, hospitalizations, if female pregnancies and deliveries.Emotional History 15 1.5 Status of any emotional, psychiatric or substance related health problems.Family History 15 1.5 Review the health history of parents, sibling(s), and grandparents to evaluate for genetic or familial patterns of health or illness that might impact your participant.Psychosocial, Educational, Occupational History 15 1.5 Include information about support systems, educational level and occupational history.  Do not ask financial income but ask if money is a cause of concern for the participant.Roles and Relationships 15 1.5 Identify the participant’s roles and relationships including membership in community based activities and other volunteer efforts.Ethnicity and Culture 15 1.5 Participant’s ethnicity and culture including any traits that might impact health care choices. Spirituality 15 1.5 Participant’s religious and spiritual needs (Spiritual needs are considerations of how the individual feels they relate to others and a higher being). Self-concept 15 1.5 What are the participant’s thoughts and feelings about who and what they are? Do they have goals for the future.Review of systems(this is not a physical assessment!) 15 1.5 This section focus on obtaining information that might not have been uncovered in other sections.  It is not a physical assessment but rather a review of systems.  Start at the head and work toward the toe asking about any alterations in the body systems.  Remember to ask questions in a way that your participant can understand and that promotes therapeutic communication. Clarity of writing 05 0.5 Content is thorough, organized and logical. Use of appropriate medical terminology without the use of qualifiers that are not measureable. Total 200 20%