nursing

NURS 6512

Week 2 Assignment Template

Part I: Comprehensive Health History

Subjective Data

Chief Complaint (CC):

History of Present Illness (HPI):

Past Medical History (PMH):

Surgical History (PSH):

Medications:

Allergies:

Preventive Health:

Social History (social determinants of health):

Review of Systems (ROS)

General:

Skin:

HEENT:

Cardiac:

Respiratory:

Gastrointestinal (GI):

Genitourinary (GU):

Musculoskeletal (MSK):

Neurologic:

Psychiatric:

Endocrine:

Hematologic/Lymphatic/Immune:

Part II: Reflection (1 page minimum)

Part 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.

For each question: • State the question • Explain why it is clinically important • Describe how the answer could influence your assessment

Part 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.

References

List 3–5 peer-reviewed references, less than 5 Years Old. Cite all sources in APA format.

Influenza Presentation

Mike Taylor

Age: 27 Sex: Male Race/Ethnicity: Hispanic Marital Status: Married Occupation: Construction worker Insurance: Private Living Situation: Lives with wife, mother, and 4-year-old son

Chief Complaint (CC): Fever and body aches for three days.

Patient Statement

About three days ago I started feeling really run down, like I was coming down with something. The next day I developed a fever — I think it was around 102 — and I’ve had chills on and off since then. My whole body aches, especially my back and legs, and I have this pounding headache that won’t go away. I’ve also had a dry cough and a sore throat.

I did feel a little short of breath yesterday when I walked up the stairs, but I wasn’t sure if that was just because I was tired. I’ve also had some nausea and haven’t really felt like eating much. I haven’t had any vomiting or diarrhea.

A few people at work have been out sick with the flu. I didn’t get my flu shot this year because last time I got it, I felt sick afterward.

I’m mostly worried because I can’t afford to miss work, and my mom lives with us — she has diabetes — so I don’t want her getting sick.

© 2026 Walden University, LLC

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.   

·

· Rubric

· NURS_6512_Module1_Assignment2_Rubric

NURS_6512_Module1_Assignment2_Rubric
Criteria	Ratings	Pts
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
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
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
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
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
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