Nursing Assignment!
Simulation Case Study:
Access Simulation Case Study #1: Obtaining a Comprehensive Health History Links to an external site. .
NO AI IS PERMITTED!
REQUIRED SOURCES:
NOTE: Utilize this text as a clinical reference to aid your analysis for the relevant areas noted. Also utilize study questions to develop your understanding of the concepts and topics presented throughout this course.
· Soriano, R. P. (2026). Bates’ guide to physical examination and history taking(14th ed.). Wolters Kluwer Health.
· Chapter 5: Clinical Reasoning
· Chapter 3, "Health History"
· Chapter 4, "Physical Examination"
· Nichol, J. R., Sundjaja, J. H., & Nelson, G. (2025). Medical historyLinks to an external site. . In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534249/
· Document: Comprehensive Health History Reference Sheet (PDF) Download Comprehensive Health History Reference Sheet (PDF)
· Document: Week 2 Case Study Assignment Template (Word) Download Week 2 Case Study Assignment Template (Word)
· U.S. Preventive Services Task Force. (n.d.). HomeLinks to an external site. . https://www.uspreventiveservicestaskforce.org/
· Centers for Disease Control and Prevention. (n.d.). Immunization schedules Links to an external site. . https://www.cdc.gov/vaccines/hcp/imz-schedules/index.html
· Centers for Disease Control and Prevention & U.S. Department of Health and Human Services, Office of Disease Prevention. (n.d.). Social determinants of health – Healthy People 2030 Links to an external site. . https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health
· Walden University, LLC. (n.d.). S imulation case study #1: Obtaining a comprehensive health historyLinks to an external site. . Walden University Canvas. https://waldenu.instructure.com
INSTRUCTIONS:
Using only the information provided in the initial patient presentation, complete a comprehensive adult health history as if you conducted the patient interview yourself.
Expand the history as appropriate by identifying and documenting expected history findings. You may include your own version of history sections as you see fit. In other words, you can formulate your own health history of the patient as long as it is properly documented.
Your written submission must include the following sections:
· Identifying Data
· Chief Complaint (in patient’s own words)
· History of Present Illness (fully developed provider-written narrative using OLDCART or OPQRST format)
· Past Medical History
· Surgical History
· Current Medications (including OTC and supplements)
· Allergies (including reactions)
· Family History
· Social History (including occupation, living situation, substance use)
· Social Determinants of Health (employment stability, financial strain, housing, transportation, access to care, ability to isolate, vaccine hesitancy)
· Vaccination History (including influenza and COVID status)
· Focused Review of Systems
Evidence-Based Practice Requirement
Your documentation must incorporate a minimum of three evidence-based scholarly references published within the last five years (≤ 5 years old). Cite all sources in APA format.
References must support:
· Clinical presentation and pathophysiology of influenza
· Risk stratification and high-risk populations
· Current influenza vaccination recommendations
· Best practices in advanced health assessment documentation
· Any portion of the “reflection” section
Acceptable Sources
· Peer-reviewed scholarly journal articles
· CDC clinical guidelines
· IDSA clinical practice guidelines
· WHO clinical guidance documents
· Evidence-based advanced practice nursing resources
Unacceptable Sources
· Patient education websites (e.g., Mayo Clinic, Cleveland Clinic, WebMD, Healthline)
· General health blogs
· Wikipedia
· Non–peer-reviewed commercial websites
· This reflection is designed to strengthen clinical reasoning by evaluating your interviewing process and identifying opportunities to enhance assessment quality.
· After completing your comprehensive health history, submit a 1-page reflection addressing the questions listed in the assignment template.
· Access Simulation Case Study #1: Obtaining a Comprehensive Health History Links to an external site. .
Rubric:
NURS_6512_Module1_Assignment2_Rubric
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NURS_6512_Module1_Assignment2_Rubric |
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Criteria |
Ratings |
Pts |
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This criterion is linked to a Learning OutcomePart I: Obtaining and Documenting a Comprehensive Health History... Demonstrates accurate and complete documentation of patient history containing only subjective data. Includes a focused (not comprehensive) review of systems. |
50 to >44.7 ptsExcellentProvides accurate and complete documentation of patient health history containing subjective data and a focused review of systems. 44.7 to >39.7 ptsGoodProvides a mostly accurate and complete documentation of patient health history containing subjective data and a focused review of systems. 39.7 to >0 ptsPoorDoes not provide documentation of patient health history; documentation is inaccurate and/or incomplete. |
50 pts |
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This criterion is linked to a Learning OutcomePart II, Section 1: Additional Questions... Identify 3–5 questions you would ask the patient to further strengthen your assessment. Make sure at least one question relates to social determinants of health. |
20 to >17.88 ptsExcellentIdentifies 3–5 questions they would ask the patient to further strengthen their assessment. At least one question relates to social determinants of health 17.88 to >15.88 ptsGoodIdentifies 3–5 questions they would ask the patient to further strengthen their assessment. None of the questions relates to social determinants of health. 15.88 to >0 ptsPoorDoes not identify 3–5 questions they would ask the patient; questions provided are unclear or incomplete. |
20 pts |
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This criterion is linked to a Learning OutcomePart II, Section 2: Professional Growth... Identify one area where you would improve your interviewing skills based on this case. Briefly explain how you plan to strengthen that area. |
15 to >13.41 ptsExcellentIdentifies one area of professional growth related to interviewing skills. Provides fully developed explanations of how they plan to strengthen their interviewing skills. 13.41 to >11.91 ptsGoodIdentifies one area of professional growth related to interviewing skills. Provides adequately developed explanations of how they plan to strengthen their interviewing skills. 11.91 to >0 ptsPoorDoes not identify one area of professional growth related to interviewing skills; explanation of how they plan to strengthen their interviewing skills is vague, unclear, or incomplete. |
15 pts |
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This criterion is linked to a Learning OutcomeUses at least 3 scholarly resources that are less than 5 years old. |
5 to >4.46 ptsExcellentUses 3 peer-reviewed scholarly sources published within the last 5 years. 4.46 to >3.96 ptsGoodUses 2 peer-reviewed scholarly sources published within the last 5 years. 3.96 to >3.46 ptsFairUses 1 peer-reviewed scholarly source published within the last 5 years. 3.46 to >0 ptsPoorDoes not use peer-reviewed scholarly sources or sources used are older than 5 years. |
5 pts |
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This criterion is linked to a Learning OutcomeSource Attribution and APA Formatting |
5 to >4.46 ptsExcellentAll sources are cited in APA format without any errors. 4.46 to >3.96 ptsGoodAll sources are cited in APA format with some minor errors. 3.96 to >3.46 ptsFairAll sources are cited with frequent APA formatting errors. 3.46 to >0 ptsPoorMissing source citations and/or minimal adherence to APA formatting rules. |
5 pts |
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This criterion is linked to a Learning OutcomeGrammar, Mechanics, and Punctuation |
5 to >4.46 ptsExcellentCorrect grammar, spelling, and punctuation with no errors. 4.46 to >3.96 ptsGoodCorrect grammar, spelling, and punctuation with few errors. 3.96 to >3.46 ptsFairCorrect grammar, spelling, and punctuation with frequent errors. 3.46 to >0 ptsPoorFrequent errors in grammar, spelling, and punctuation that interfere with comprehension. |
5 pts |
Total Points: 100