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milestone_1_guidelines.docx
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.
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 |
|
Milestone #1 Health History.docx Rev. 8-6-13 jm |
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