NR 305 Assignment Course Project Milestone 1: Health History Guidelines

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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 Instructor’s 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.

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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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