Students will demonstrate knowledge of interviewing skills, the components of a health history, recording the history data, and assigning three priorities after reviewing the data. A health history will be completed and submitted according to the grading rubric and course schedule. Students will submit a detailed subjective health history of a volunteering adult over 50 on the provided form. Students should not give identifying data on the patient only the demographics requested in the grading rubric.
The health history assignment is SUBJECTIVE – interviewing and questioning the patient.
Each student will complete a comprehensive health history following the rubric provided below:
Instructions:
Comprehensive health history is all subjective data. Consider the health history a chance for the patient to tell their story.
Find a friend or relative to complete an entire health history.
After completing, a detailed health history, students will document the results of the health history APA7information on how to complete a health history is found in Chapter 4, pages 70 to 88.
Steps for the Health History:
Subject Criteria Possible Points
Patient Demographics
Gender, age, ethnicity, and other social demographics as indicated (self-pay, Insurance)
5
Chief Complaint
Use the patients own wordsone or more symptoms or concerns cause the patient to seek care.
Elaborate on the chief complaint; describes how each symptom developed.
Includes the patients thoughts and feelings about the illness.
5
History of Present Illness
Appropriate dimensions of cardinal symptoms are listed (including location, severity, quality, setting, chronology, aggravating/alleviating, and associated manifestations)
HPI narrative flows smoothly in a logical fashion
For those who favor mnemonics, the 8 dimensions of a medical problem can be easily recalled using OLD CARTS (Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity).
10
Past Medical History
Lists childhood illnesses
Lists adult illnesses with dates for at least three categories: medical, surgical, and psychiatric.
Medication, Allergies
Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety.
5
Current Health Status
Summary of general health status related to the present illness.
5
Family History
Narrative and Genogram
https://genopro.com/genogram/medical/Links to an external site.
Outlines or diagrams of age and health or age and cause of death of siblings, parents, grandparents, and children.
Documents the presence or absence of specific illnesses in the family (e.g., hypertension, coronary artery disease)
The family pedigree shows at least three generations and involves the use of standardized symbols, which mark individuals affected with a specific diagnosis to allow for easy identification.
10
Risk assessment based on family history
Family history of a known or suspected genetic condition
Ethnic predisposition to certain genetic disorders
Consanguinity (blood relationship of parents)
Multiple affected family members with the same or related disorders
Earlier than expected age of onset of disease
Diagnosis in less-often-affected sex
10
Past Surgical History
Were they ever operated on, even as a child?
What year did this occur?
Were there any complications?
5
Social History
Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur?
Do they drink alcohol? If so, how much per day and what type of drink?
Any drug use, past or present, should be noted.
Work, family, friends, community support systems,
5
Sexual Activity
Do they participate in intercourse? With persons of the same or opposite sex?
Are they involved in a stable relationship?
Do they use condoms or other means of birth control?
Married? The health of the spouse? Divorced? Past sexually transmitted diseases?
Do they have children? If so, are they healthy? Do they live with the patient?
5
Work/Hobbies/Other
What sort of work does the patient do?
Have they always done the same thing? Do they enjoy it?
If retired, what do they do to stay busy? Any hobbies?
5
Review of systems (ROS)
Documentation of the presence or absence of common symptoms related to each major body system.
Consider asking a series of questions going from head to toe.
The questions asked to reflect an array of standard and critical clinical conditions (heart disease, diabetes, arthritis)
These disorders would only be recognized if the patient were explicitly prompted.
Format
General/skin/sleep
HEENT
Respiratory
Cardiovascular
Musculoskeletal
Endocrine
Gastrointestinal and Urinary
Neuro/psyc
10
Prevention and Health Promotion
At least one prevention activity.
At least three health promotion recommendations.
10
APA Guidelines & Writing Style
APA (title page, margins, page numbers, headings, subheadings, citations); spelling; writing straightforward, concise, and professional.
10
Total 100
Rubric
Health History Rubric
Health History Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomePatient Demographics
5 pts
Outstanding
States all 9 demographic information, including ethnicity, preferences, and ethnicity .
3 pts
Acceptable
Includes 3 to 7 items of biographical data
0 pts
Unacceptable
Biographical data includes less than 2 items
5 pts
This criterion is linked to a Learning OutcomeChief Complaint (CC)
5 pts
Outstanding
Single CC; clearly stated from the patients perspective. Identifies sources of information
3 pts
Acceptable
Single chief complaint clearly stated
0 pts
Unacceptable
Too many complaints; too much information; not based on patients perspective
5 pts
This criterion is linked to a Learning OutcomeHistory of Present Illness (HPI)
10 pts
Outstanding
Meets expectations and is also pt-centered focusing on the pts of symptoms (e.g. does not use medical terms, like angina, to describe chest pain). Accurately conveys pertinent medical eval up to time of interaction.
6 pts
Acceptable
Symptoms fully characterized (quality, duration, severity, etc). Chronology is evident. Well organized
0 pts
Unacceptable
Symptoms not fully characterized (quality, duration, severity, etc). No discernable chronology.
10 pts
This criterion is linked to a Learning OutcomePast Medical History (PMH)
5 pts
Outstanding
Includes more detailed but pertinent qualifying info (treatment course, recent studies, studies or sxs documenting change in natl h/o disease process). List of all medications.Detail on OTC/supplements. Meds matched to indication. Pts s of adverse events and delineation b/w allergy and reaction.
3 pts
Acceptable
PMH with basic qualifying information (date of dx, last testing, e.g.) Meds with doses; and OTC meds. List of allergies with reactions.
0 pts
Unacceptable
Just lists conditions. No mention of medications. Allergies and reactions are not included.
5 pts
This criterion is linked to a Learning OutcomeCurrent Health Status
5 pts
Outstanding
Student identifies correctly patient lifestyle and functioning. Provides examples.
3 pts
Acceptable
The student describes the patient’s present health status and lifestyle. However, there are no examples.
0 pts
Unacceptable
The student does not describe the patient current health status and lifestyle.
5 pts
This criterion is linked to a Learning OutcomeFamily History Narrative and Genogram
10 pts
Outstanding
addresses key elements of past and family health history. Student shows 3 generations of family on Genogram. Denotes family relationships using accurate symbols with supporting explanations.
6 pts
Acceptable
addresses all key elements. Student shows 3 generations of family on genogram.
0 pts
Unacceptable
Does not develop a complete family history. Genogram is not included in assignment.
10 pts
This criterion is linked to a Learning OutcomeRisk assessment based on family history
10 pts
Outstanding
Identify health patterns that affect different generations and ways to promote good health to combat these patterns. identify at least three specific health risks or diseases that have been passed down through generations.
6 pts
Acceptable
Discussion articulates generational health patterns but does not fully address health promotion activities to combat these health patterns. Identified and communicated 2-3 health risk/disease patterns through the generations depicted.
0 pts
Unacceptable
Discussion lacks depth in relation to patterns of health and health promotion activities to combat these patterns Identified and communicates one health risk/disease pattern throughout generations depicted.
10 pts
This criterion is linked to a Learning OutcomePast Surgical History
5 pts
Outstanding
The student identifies surgical history with dates and outcomes.
3 pts
Acceptable
The student identifies past surgical history but omits dates and outcomes.
0 pts
Unacceptable
Past surgical history is not present.
5 pts
This criterion is linked to a Learning OutcomeSocial History
5 pts
Outstanding
Relevant, thorough, accurate, in-depth social patient history. Including alcohol and drug history.
3 pts
Acceptable
The general patient’s social history was presented. However, omits some of the criteria requirements.
0 pts
Unacceptable
Minimal patient social history presented
5 pts
This criterion is linked to a Learning OutcomeSexual Activity
5 pts
Outstanding
The sexual history detects most key and relevant information that triggers prevention activities.
3 pts
Acceptable
The sexual history is detailed. However, it does not trigger future prevention activities.
0 pts
Unacceptable
The sexual history is disorganized and does not follow recommendations.
5 pts
This criterion is linked to a Learning OutcomeWork/Hobbies/Other
5 pts
Outstanding
Succinct yet detailed prose with hobbies and/or other details to give a sense of pt prior to acute illness
3 pts
Acceptable
List some hobbits and occupations.
0 pts
Unacceptable
Does not mention hobbies or other activities prior to illness.
5 pts
This criterion is linked to a Learning OutcomeReview of systems (ROS)
10 pts
Outstanding
Student provides an adequate review of systems documentation that covers the majority of systems
6 pts
Acceptable
Student provides a limited review of systems documentation.
0 pts
Unacceptable
Too many complaints; too much information; not based on patients perspective
10 pts
This criterion is linked to a Learning OutcomePrevention and Health Promotion
10 pts
Outstanding
The student provides a comprehensive list of prioritized recommendations for health promotion substantiated with referenced rationales.
6 pts
Acceptable
Student provides at least 3 prioritized recommendations for health promotion with rationales provided.
0 pts
Unacceptable
Student provides 0-1 recommendations with no rationales provided
10 pts
This criterion is linked to a Learning OutcomeAPA Guidelines & Writing Style
10 pts
Outstanding
>2 scholarly resources used to support the analysis .<2 spelling, grammatical, punctuation errors Follows APA guidelines. 6 pts Acceptable 1-2 scholarly resources utilized. 2-5 spelling, grammatical, and punctuation errors. Follows APA guidelines 0 pts Unacceptable Lacks scholarly resources. >5 spelling, grammatical, punctuation errors. Do not follow APA guidleines.
10 pts
Total Points: 100
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