Patient Health History
This assignment should be at least a 6-to-7-page summary in APA format documenting the findings of a comprehensive health history excluding a title and a reference page. The paper should not exceed 15 pages in length.
The title page and the reference page are required.
For this assignment, you will conduct a health history as part of your future physical assessment assignment.
Do not complete the assignment on a patient in your care at your place of employment due to HIPAA. The volunteer must be an adult.
The volunteer you will be assessing will be considered “normal” or nearly normal in most situations.
They are not required to be without illness or disease processes, this is just who is normally available to students to assess.
However, students will need to ensure even normal findings are addressed according to the assessment guidelines.
Example: the volunteer does not have an IV, but you will still need to communicate that this is the case in your documentation.
Avoid oversimplifying your assessment and documentation.
For example, if assessing peripheral pulses, avoid writing “peripheral pulses assessed.” Instead, document “Pedal pulses assessed bilaterally. Both pulses were 2+ with a rate of 78 bpm.”
Create a heading for each criterion listed in the rubric.
· Identifying Data and Source of History
-Maintain client's confidentiality. DO NOT include their name.
-Date health history was conducted
-Date of Birth
-Ethnicity/Race
-Sex/Gender if different from sex assigned at birth
-Primary language
-Marital status
-Living arrangements/who do they with? Do they utilize hospice or home health services? If so, what do they use home health for?
Religious preferences or practices that affect health care?
-Occupation?
-General impression of the patient (for example, are they in acute distress?) Appropriate body language and hygiene? Look stated age?
-General mood?
-Make sure the information was thorough and met the guidelines above.
· Chief Complaint
-The main reason for seeking healthcare and the situational events surrounding it. Describe fully (this will likely be fictional if the volunteer is healthy).
-What does the client expectation does the client have for the health care providers involved in their care?
-What does the client hope to accomplish? What does health mean to the client?
-Demonstrate the components of symptom analysis using the “Seven Attributes of a Symptom.”
· Medications
-Limit this to 5 examples
-Prescription medications (dose, route, frequency, reason for prescription/reason for PRN).
-Over-the-counter medications, including herbs (name, dose, frequency, route):
· Allergies
-Allergies and reactions when exposed to allergen?
-How were these reactions treated?
· Current and Past Medical and Surgical History
-What diseases did you have as a child (example: Chicken pox, measles, mumps, etc.)?
-Current chronic medical conditions and its impact on daily living?
-Previous hospitalizations? (Year, reason, impact)?
-Previous accidents or injuries (for example care accident)?
-Up to date on vaccinations?
-Uses any assistive devices?
-Previous surgeries? (Year, reason, impact or result)
-Problems with anesthesia (ask only if this is indicated)? If yes, describe.
· Family History
-Notable diseases, disorders, or disabilities of grandparents?
-Notable diseases, disorders, or disabilities of parents?
-Notable diseases, disorders, or disabilities of siblings?
-Notable diseases, disorders, or disabilities of children?
-Indicate if a family member is not applicable (such as patient does not have children). Indicate if patient or family member adopted or not.
· Personal Social History
-Alcohol use: never used, past user, present user, details
For past and present alcohol users only:
-Have you ever felt the need to cut down on your drinking?
-Have you ever felt annoyed by criticism of your drinking?
-Have you ever felt guilty about your drinking?
-Have you ever had the need for an eye-opener to treat a hangover or to steady your nerves?
-Tobacco use: never used, past user, present user, details (smoked? Dipped? How frequently, how much (#of cartons, #cigars, #cigarettes, for how many years, etc.)
-Recreational drug use: never used, past user, present user, include details
-In home or work environment (other smokers, on the job chemicals such as pesticides, etc.)
-Exercise patterns
-Sleep patterns
Write up/Documentation of assessment.
Appropriate ROS questions in each system area, including documentation of pertinent positives and negatives.
Use correct verbiage in your documentation. For example, instead of saying “wet breath sounds,” say “crackles noted bilaterally in lower lung lobes, upper lobes clear.”
Do not use the term “WNL,” within normal limits, or anything similar. This assignment is not intended to be a “document by exception” approach. Instead, document exactly what you assess even if it is normal.