The health history assignment is SUBJECTIVE – interviewing and questioning the p

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The health history assignment is SUBJECTIVE – interviewing and questioning the p

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 APA7—information on how to complete a health history is found in Chapter 4, pages 70 to 88.
Steps for the Health History:
SubjectCriteriaPossible Points
Patient DemographicsGender, age, ethnicity, and other social demographics as indicated (self-pay, Insurance)
5
Chief Complaint Use the patient’s own words—one or more symptoms or concerns cause the patient to seek care.
Elaborate on the chief complaint; describes how each symptom developed.
Includes the patient’s thoughts and feelings about the illness.
5
History of Present IllnessAppropriate 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 HistoryLists 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 historyFamily 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 HistoryWere they ever operated on, even as a child?
What year did this occur?
Were there any complications?
5
Social HistoryHave 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 ActivityDo 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/OtherWhat 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.
FormatGeneral/skin/sleep
HEENT
Respiratory
Cardiovascular
Musculoskeletal
Endocrine
Gastrointestinal and Urinary
Neuro/psyc
10
Prevention and Health PromotionAt least one prevention activity.
At least three health promotion recommendations.
10
APA Guidelines & Writing StyleAPA (title page, margins, page numbers, headings, subheadings, citations); spelling; writing straightforward, concise, and professional.
10
Total100
Rubric
Health History Rubric
Health History Rubric
CriteriaRatingsPts
This criterion is linked to a Learning OutcomePatient Demographics
5 ptsOutstanding
States all 9 demographic information, including ethnicity, preferences, and ethnicity .
3 ptsAcceptable
Includes 3 to 7 items of biographical data
0 ptsUnacceptable
Biographical data includes less than 2 items
5 pts
This criterion is linked to a Learning OutcomeChief Complaint (CC)
5 ptsOutstanding
Single CC; clearly stated from the patient’s perspective. Identifies sources of information
3 ptsAcceptable
Single chief complaint clearly stated
0 ptsUnacceptable
Too many complaints; too much information; not based on patient’s perspective
5 pts
This criterion is linked to a Learning OutcomeHistory of Present Illness (HPI)
10 ptsOutstanding
Meets expectations and is also pt-centered focusing on the pt’s description 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 ptsAcceptable
Symptoms fully characterized (quality, duration, severity, etc). Chronology is evident. Well organized
0 ptsUnacceptable
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 ptsOutstanding
Includes more detailed but pertinent qualifying info (treatment course, recent studies, studies or sx’s documenting change in nat’l h/o disease process). List of all medications.Detail on OTC/supplements. Meds matched to indication. Pts’ descriptions of adverse events and delineation b/w allergy and reaction.
3 ptsAcceptable
PMH with basic qualifying information (date of dx, last testing, e.g.) Meds with doses; and OTC meds. List of allergies with reactions.
0 ptsUnacceptable
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 ptsOutstanding
Student identifies correctly patient lifestyle and functioning. Provides examples.
3 ptsAcceptable
The student describes the patient’s present health status and lifestyle. However, there are no examples.
0 ptsUnacceptable
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 ptsOutstanding
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 ptsAcceptable
addresses all key elements. Student shows 3 generations of family on genogram.
0 ptsUnacceptable
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 ptsOutstanding
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 ptsAcceptable
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 ptsUnacceptable
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 ptsOutstanding
The student identifies surgical history with dates and outcomes.
3 ptsAcceptable
The student identifies past surgical history but omits dates and outcomes.
0 ptsUnacceptable
Past surgical history is not present.
5 pts
This criterion is linked to a Learning OutcomeSocial History
5 ptsOutstanding
Relevant, thorough, accurate, in-depth social patient history. Including alcohol and drug history.
3 ptsAcceptable
The general patient’s social history was presented. However, omits some of the criteria requirements.
0 ptsUnacceptable
Minimal patient social history presented
5 pts
This criterion is linked to a Learning OutcomeSexual Activity
5 ptsOutstanding
The sexual history detects most key and relevant information that triggers prevention activities.
3 ptsAcceptable
The sexual history is detailed. However, it does not trigger future prevention activities.
0 ptsUnacceptable
The sexual history is disorganized and does not follow recommendations.
5 pts
This criterion is linked to a Learning OutcomeWork/Hobbies/Other
5 ptsOutstanding
Succinct yet detailed prose with hobbies and/or other details to give a sense of pt prior to acute illness
3 ptsAcceptable
List some hobbits and occupations.
0 ptsUnacceptable
Does not mention hobbies or other activities prior to illness.
5 pts
This criterion is linked to a Learning OutcomeReview of systems (ROS)
10 ptsOutstanding
Student provides an adequate review of systems documentation that covers the majority of systems
6 ptsAcceptable
Student provides a limited review of systems documentation.
0 ptsUnacceptable
Too many complaints; too much information; not based on patient’s perspective
10 pts
This criterion is linked to a Learning OutcomePrevention and Health Promotion
10 ptsOutstanding
The student provides a comprehensive list of prioritized recommendations for health promotion substantiated with referenced rationales.
6 ptsAcceptable
Student provides at least 3 prioritized recommendations for health promotion with rationales provided.
0 ptsUnacceptable
Student provides 0-1 recommendations with no rationales provided
10 pts
This criterion is linked to a Learning OutcomeAPA Guidelines & Writing Style
10 ptsOutstanding
>2 scholarly resources used to support the analysis .<2 spelling, grammatical, punctuation errors Follows APA guidelines. 6 ptsAcceptable 1-2 scholarly resources utilized. 2-5 spelling, grammatical, and punctuation errors. Follows APA guidelines 0 ptsUnacceptable Lacks scholarly resources. >5 spelling, grammatical, punctuation errors. Do not follow APA guidleines.
10 pts

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