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, âDoes not want to disclose.â
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 âfrequently,â or consuming 4
servings of vegetables/day instead of âincreasedâ vegetable servings.
4. Save the file by clicking âSave asâ and adding your last
name to the file name, e.g., âNR305_Milestone1_Form_Smithâ
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 Research Topics – Criteria
Category
Points
%
Description
Biographical
Data
10
6
Date
of health history, clientâs 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 clientâs 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 clientâs
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
Clientâs ethnicity and culture,
and physical and social characteristics that influence healthcare decisions.
Spirituality
5
3
Clientâs religious and spiritual
needs. (Spirituality refers to the individualâs 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 Paper Writing Service – Topic Examples – Rubric
Assignment Research Topics – 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 pointsCourse Project Milestone 1: Health History FormYour Name: Date:
Your Instructorâs 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 âSave asâ and save the file with the assignment
name and your last name, e.g., âNR305_Milestone1_Form_Smithâ 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, âDoes not want to disclose.â
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:
