Guidelines for Course Project Milestone 1: Health History Purpose The student will obtain a health history on a willing, non-related, 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.” Directions 1. Find an adult who is not related to you who is willing to let you take a health history. 2. 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. 3. Review the examples in Chapter 10 of your textbook to gain insight into how to document the health history. 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. 4. Save the file by clicking “Save as” and adding your last name to the file name, e.g., “NR305_Milestone1_Form_Smith” 5. 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 Criteria Category Points % Description Biographical Data 10 6 Date of health history, client’s 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 client’s 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 client’s 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 Client’s ethnicity and culture, and physical and social characteristics that influence healthcare decisions. Spirituality 5 3 Client’s religious and spiritual needs. (Spirituality refers to the individual’s 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 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 Rubric Assignment Criteria Exceeds Minimum Requirements Meets Minimum Requirements Partially Meets or Does Not Meet Minimum Requirements Biographical Data 10 points All required criteria included. No errors. 10 points No more than one required elements missing 8 points More than two required elements missing. 0-7 points Present Health History/Illness 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Health Beliefs and Practices 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Medications 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Past History 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Emotional History 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Family History 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Psychosocial/ Occupational History 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Roles and Relationships 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Ethnicity and Culture 10 points All required criteria included. No errors. 10 points No more than one required elements missing 8 points More than two required elements missing. 0-7 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. 0-3 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. 0-3 points Review of Systems 20 points All required criteria included. No errors. 16-20 points No more than three required elements missing did not include information about functional patterns of each system. 10-15 points More than three required elements missing. Total body systems and/or functional patterns missing. 0-9 points Clarity of writing 5 points Organized logically and written clearly with good structure 4-5 points Lacks some organization & clarity. Uses words such as frequently, increased, decreased. 2-3 points Lacks logical organization; difficult to read. Uses words such as frequently, increased, decreased. 0-1 points Total Points Possible = 175 points 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 in Doc Sharing to complete the information below. This assignment is worth 175 points, with 5 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language. Type your answers on this form. Click “Save as” and save the file with the assignment name and your last name, e.g., “NR305_Milestone1_Form_Smith” When you are finished, submit the form to the Milestone #1 Dropbox by the deadline indicated in your guidelines. 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.” BIOGRAPHICAL DATA (10 pts) 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 (15 pts) Reason for seeking care: Health patterns: Health goals: HEALTH BELIEFS AND PRACTICES (15 pts) Beliefs and practices: Factors influencing healthcare decisions: Related traits, habits or acts: MEDICATIONS (15 pts) Prescription medications: Over-the-counter medications: Herbals: PAST HISTORY (15 pts) 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 pts) Mental, emotional or psychiatric problems: FAMILY HISTORY (15 pts) Father: Mother: Siblings: Grandparents: PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts) Occupational history: Educational level: Financial background: ROLES AND RELATIONSHIPS (15 pts) Significant others: Support systems: ETHNICITY AND CULTURE (10 pts) Ethnicity and culture: Physical and social characteristics that influence healthcare decisions: SPIRITUALITY (5 pts) Religious and spiritual needs: SELF-CONCEPT (5 pts) View of self-worth: Future plans: REVIEW OF SYSTEMS (20 pts) 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:
