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

February 2, 2024
  • 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:

Subject Criteria Possible Points
Patient Demographics
  • Gender, 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 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 patient’s 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 patient’s 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 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 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 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 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 patient’s 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

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