1. Find an adult who is not related to you who is willing to let you take a health history.
Tysha625
milestoneproject.docx1. Find an adult who is not related to you who is willing to let you take a health history.
2. Download the required 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.
3. 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.
4. Save the file by clicking Save as and adding your last name to the file name, for example, NR305_Milestone1_Form_Smith. You must save as a .docx file, but do not save as a "Word Pad" document.
5. Submit the completed form by Sunday, 11:59 p.m. MT at the end of Week 4.
6. Please post questions in the Q & A Forum so the entire class may view the answers.
**Academic Integrity Reminder**
Please see the grading criteria and rubrics on this page.
NOTE: Please use your browser's File setting to save or print this page.
Rubric
NR305 Milestone 1 Rubric
|
NR305 Milestone 1 Rubric |
|||||||
|
Criteria |
Ratings |
Pts |
|||||
|
This criterion is linked to a Learning OutcomeBiographical Data 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, and so on. |
|
15.0 pts |
|||||
|
This criterion is linked to a Learning OutcomePresent Health History/Illness Reasons for seeking care, health patterns, and health goals. |
|
20.0 pts |
|||||
|
This criterion is linked to a Learning OutcomeHealth Beliefs and Practices Health beliefs and practices including factors that influence their healthcare decisions, related traits, habits, or acts that affect a client’s health. |
|
15.0 pts |
|||||
|
This criterion is linked to a Learning OutcomeMedications 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. |
|
20.0 pts |
|||||
|
This criterion is linked to a Learning OutcomePast History Childhood diseases, immunizations, allergies, blood transfusions, major illnesses, injuries, hospitalizations, labor and deliveries, surgeries, and use of alcohol, tobacco and illicit drugs. |
|
20.0 pts |
|||||
|
This criterion is linked to a Learning OutcomeEmotional History Includes information about any mental, emotional, or psychiatric health problems. |
|
15.0 pts |
|||||
|
This criterion is linked to a Learning OutcomeFamily History 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. |
|
20.0 pts |
|||||
|
This criterion is linked to a Learning OutcomePsychosocial/ Occupational History Includes information about occupational history, educational level, and financial background. |
|
15.0 pts |
|||||
|
This criterion is linked to a Learning OutcomeRoles and Relationships 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). |
|
15.0 pts |
|||||
|
This criterion is linked to a Learning OutcomeEthnicity and Culture Client’s ethnicity and culture, and physical and social characteristics that influence healthcare decisions. |
|
15.0 pts |
|||||
|
This criterion is linked to a Learning OutcomeSpirituality Client’s religious and spiritual needs. (Spirituality refers to the individual’s sense of self in relation to others and a higher being.) |
|
5.0 pts |
|||||
|
This criterion is linked to a Learning OutcomeSelf-Concept Includes information on how they view their self-worth and plans for the future. |
|
5.0 pts |
|||||
|
This criterion is linked to a Learning OutcomeReview of Systems 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. |
|
25.0 pts |
|||||
|
This criterion is linked to a Learning OutcomeClarity of Writing 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. |
|
20.0 pts |
|||||
|
Total Points: 225.0 |
