CHAMBERLIAN NR 305 WEEK 4 COURSE PROJECT MILESTONE 1 LATEST 2016
NOVEMBER COURSE PROJECT MILESTONE
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NR 305 WEEK 4 COURSE PROJECT MILESTONE 1
LATEST 2016 NOVEMBER COURSE PROJECT MILESTONE 1:HEALTH HISTORY GUIDELINES AND
GRADING RUBRIC
PURPOSE The student will obtain
a health history on a willing, nonrelated, 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 200 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 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, “Does not want to disclose.”If the client fails to disclose answers to
several items, you will need to find another client who is willing to share.
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 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. 5. Submit the completed form to the Dropbox
by Sunday, 11:59 p.m. MT at the end of Week 4. 6. Please post questions in the
weekly Q&A Forumsso the entire class may view the answers. Course Project
Milestone #1: Health History Form Your Name: Date: Your Instructor’s 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 200 points, with 10 points awarded for clarity of writing, which means
the use of proper grammar, spelling, and medical language. Type your answers on
this form. Click Save as and save the file with the assignment name and your
last name, for example, NR305_Milestone1_Form_Smith. 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, “Does not
want to disclose.”If the client fails to disclose answers to several items, you
will need to find another client who is willing to share. BIOGRAPHICAL DATA (10
points) 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 (20
points) Reason for seeking care: Health patterns: Health goals: HEALTH BELIEFS
AND PRACTICES (15 points) Beliefs and practices: Factors influencing healthcare
decisions: Related traits, habits or acts: MEDICATIONS (20 points) (Please
refer to your assignment guidelines.) Prescription medications:
Over-the-counter medications: Herbals: PAST HISTORY (20 points) 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 points) Mental,
emotional or psychiatric problems: FAMILY HISTORY (20 points) Father: Mother:
Siblings: Grandparents: PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 points)
Occupational history: Educational level: Financial background: ROLES AND
RELATIONSHIPS (15 points) Significant others: Support systems: ETHNICITY AND
CULTURE (10 points) Ethnicity and culture: Physical and social characteristics
that influence healthcare decisions: SPIRITUALITY (5 points) Religious and
spiritual needs: SELF-CONCEPT (5 points) View of self-worth: Future plans: REVIEW
OF SYSTEMS (20 points) (Please refer to your assignment guidelines and Chapter
4 of your text. This is not a physical examination.) 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:
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