Demographics

Initials, age, race/ethnicity, gender, occupation. Include a sentence of who is providing the health history.

Perception of Health

Provide the client’s perception of health—include what they stated in quotation marks.

Past Medical History

Include the client’s past medical history

Family Medical History

Include medical history for mother, father, siblings, maternal and paternal grandparents

Continue documenting the health history as described in the RUA guidelines and from the information in chapter 4 of your text. I advise using headings, to ensure that you address all components of the assignment. When you get to the review of systems, it can be documented this way, for example:

Review of Systems

Head

Denies history of trauma, states frequent headaches for the last 3 weeks, occurring daily in the afternoon (this is an example—you document what your client told you)

Skin

Denies history of eczema, psoriasis, rashes. States freckles on cheeks and nose (again—document what your client told you)

Eyes

Continue as before. If the client does not have any concerns, document denies _______, ________, and ______, using the information from chapter 4 to guide you in the specific questions to ask regarding each body system.

1

Running head: HEALTH HISTORY

5

HEALTH HISTORY

Health History

Samantha Candela

Chamberlain College of Nursing

NR 302: Health Assessment

2/12/2016

Professor Moersch

Health History Assessment

I choose to do a health assessment on a family friend. I will use AH has her initials.

Demographic Data

AH is 63 years old, a female, Caucasian, and lives in a house. She lives in a rural area where she lives alone but has family close by.

Perception of Health

To her healthy means being in good health, getting regular exercise, and eating nutritious food. Unhealthy to her means not being in good health, overweight, and eating bad foods. She feels like she is between healthy and unhealthy. She is not in the best health, exercises once a week, and eats good most of the time. She would like to increase her health and the amount of exercise she gets.

Past Medical History

Her past medical history includes degenerative disc disease, high blood pressure, hyperlipemia, depression, anxiety, COPD, asthma, emphysema, diverticulitis, and osteoporosis. Her past surgical history includes neck and back surgery, removal of gallbladder, removal of cataract, and hysterectomy. The medications she takes daily include a Spiriva inhaler, allegra, valium, Zoloft, gabapentin, Lopressor, and protonix.

Family Medical History

Both of her parents had high blood pressure, which lead to her high blood pressure. Her mother had asthma, which increased her chance of having it. Her father had lung cancer from smoking cigarettes. Her mother was anemic and had to have a lot of blood transfusions.

Review of Systems

The only skin issue that she has is eczema. Her hair has some grey in it and her nails are fine. She doesn’t have any headaches, head injury, or dizziness. She has some pain in her neck when she turns her head to the right. She doesn’t have any lymphatic issues. She has decreased vision and had some cataracts. She wears eyeglasses and had cataract removal surgery in June 2015. She doesn’t have any earaches or infections and her hearing is good. She has allergies to pollen and dust but no other major sinus issue. Her mouth and throat look good, no mouth pain, sore throat, toothaches, or lesions. She has asthma and emphysema, which causes her to have shortness of breath. Even with her breathing problems she can still take care of herself, cook, and clean. Her only heart related use is high blood pressure and she controls that with medication and controls her salt intake.

Developmental Considerations

She has had asthma since she was a little girl and this has caused her some issues growing up. She couldn’t play sports and play with friends for long because she would start having trouble breathing. She did not have many friends growing up and had trouble with weight; she always thought that her asthma caused this.

Cultural Considerations

Growing up she was always interested in going to church but her family wasn’t very religious. She always wanted to study her bible and her father would always have mean comments to say to her. This made it hard for her to go to church and be able to have a religious connection.

Psychosocial Considerations

She lost her husband almost a year ago and has had trouble with wanting to be social. She doesn’t like to attend social events because that was something her and her husband always used to do together. Her children are great about coming to visit her. At least one of them comes by daily and they have a weekly family night.

Collaborative Resources

Her family helps her by visiting everyday and going to any doctor appointments with her. She has a group of friends that go to church every Sunday together then go to lunch afterward. Her neighbor and her get together a few days of the week and walk to get exercise.

Reflection

This interaction helped me to practice some of the skills I learned in health assessment. We were able to talk about her medical history well since I know a lot of the medical terms and she also does because of how much she has had to be at hospitals. During the review of systems she had trouble understanding some of the questions I asked but we overcame it by me explaining each subject. I now realized I should have asked her more about any cultural issues.

References

American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.

Jarvis, C., Tarlier, D., Pelt, L. V., Andrews, M. E., & Jarvis, C. (n.d.). Physical examination and health assessment (7th ed.).

Health History Worksheet This worksheet is used to assist the student in gathering and organizing information when conducting a health history.

Family Member Description Paternal grandfather

First and last initials: L. M. Birthdate: April 11 1916 Death date: April 1984 Occupation: Private business man Education: some college Primary language: English Health summary: passed from lymphoma and lung cancer

Paternal grandmother First and last initials: C. M. Birthdate: May 20 1919 Death date: December 1980 Occupation: House wife Education: high school Primary language: English Health summary: passed from aneurism

Father First and last initials: W. M. Birthdate: October 25 1959 Death date: Alive Occupation: Failure Analysis Engineer at NASA Education: Bachelors from Mississippi State Primary language: English Health summary: Severe neck Arthritis

Father’s siblings- Summary of any significant health issues

One sibling with cancer, one sibling with fibromyalgia

Maternal grandfather First and last initials: Unknown Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Maternal grandmother First and last initials: E. V. Birthdate: June 1940 Death date: August 1978 Occupation: House wife Education: none Primary language: Spanish Health summary: passed from Stomach cancer

Mother First and last initials: R. V. M. Birthdate: July 1 1961 Death date: Alive Occupation: house wife Education: Some high school Primary language: Spanish Health summary: No health conditions

Mother’s siblings- Summary of any significant health issues No health conditions Adult Participant

First and last initials: B.M. Birthdate: July 27 1998 Death date: Alive Occupation: Student Education: College Primary language: English Health summary: No serious health conditions

Adult participant’s siblings Summary of any significant health issues None Adult participant’s spouse/significant other

First and last initials: N/A Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Adult participant’s children- Up to 4 children N/A Child #1 first and last initials:

Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Child #2 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Child #3 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Child #4 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Family Member Description Paternal grandfather

First and last initials: L. M. Birthdate: April 11 1916 Death date: April 1984 Occupation: Private business man Education: some college Primary language: English Health summary: passed from lymphoma and lung cancer

Paternal grandmother First and last initials: C. M. Birthdate: May 20 1919 Death date: December 1980 Occupation: House wife Education: high school Primary language: English Health summary: passed from aneurism

Father First and last initials: W. M. Birthdate: October 25 1959 Death date: Alive Occupation: Failure Analysis Engineer at NASA Education: Bachelors from Mississippi State Primary language: English Health summary: Severe neck Arthritis

Father’s siblings- Summary of any significant health issues

One sibling with cancer, one sibling with fibromyalgia

Maternal grandfather First and last initials: Unknown Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Maternal grandmother First and last initials: E. V. Birthdate: June 1940 Death date: August 1978 Occupation: House wife Education: none Primary language: Spanish Health summary: passed from Stomach cancer

Mother First and last initials: R. V. M. Birthdate: July 1 1961 Death date: Alive Occupation: house wife Education: Some high school Primary language: Spanish Health summary: No health conditions

Mother’s siblings- Summary of any significant health issues No health conditions Adult Participant

First and last initials: B.M. Birthdate: July 27 1998 Death date: Alive Occupation: Student Education: College Primary language: English Health summary: No serious health conditions

Adult participant’s siblings Summary of any significant health issues None Adult participant’s spouse/significant other

First and last initials: N/A Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Adult participant’s children- Up to 4 children N/A Child #1 first and last initials:

Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Child #2 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Child #3 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Child #4 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Family Member Description Paternal grandfather

First and last initials: L. M. Birthdate: April 11 1916 Death date: April 1984 Occupation: Private business man Education: some college Primary language: English Health summary: passed from lymphoma and lung cancer

Paternal grandmother First and last initials: C. M. Birthdate: May 20 1919 Death date: December 1980 Occupation: House wife Education: high school Primary language: English Health summary: passed from aneurism

Father First and last initials: W. M. Birthdate: October 25 1959 Death date: Alive Occupation: Failure Analysis Engineer at NASA Education: Bachelors from Mississippi State Primary language: English Health summary: Severe neck Arthritis

Father’s siblings- Summary of any significant health issues

One sibling with cancer, one sibling with fibromyalgia

Maternal grandfather First and last initials: Unknown Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Maternal grandmother First and last initials: E. V. Birthdate: June 1940 Death date: August 1978 Occupation: House wife Education: none Primary language: Spanish Health summary: passed from Stomach cancer

Mother First and last initials: R. V. M. Birthdate: July 1 1961 Death date: Alive Occupation: house wife Education: Some high school Primary language: Spanish Health summary: No health conditions

Mother’s siblings- Summary of any significant health issues No health conditions Adult Participant

First and last initials: B.M. Birthdate: July 27 1998 Death date: Alive Occupation: Student Education: College Primary language: English Health summary: No serious health conditions

Adult participant’s siblings Summary of any significant health issues None Adult participant’s spouse/significant other

First and last initials: N/A Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Adult participant’s children- Up to 4 children N/A Child #1 first and last initials:

Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Child #2 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Child #3 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Child #4 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary:

An example Family Member Description Paternal grandfather

First and last initials: RL

Birthdate: 1921 Death date: 1981 Occupation: Retired as a coal miner Education: 6th grade Primary language: English

Health summary: He was diagnosed with chronic lung disease, diabetes, and hypertension. He died from a heart attack.

Paternal grandmother First and last initials: ML

Birthdate: 1932 Death date: 1998 Occupation: House wife Education: Does not want to disclose Primary language: English

Health summary: Diagnosed with chronic lung disease from smoking cigarettes. Died from heart failure.

This example points to common problems among this generation on both sides of the Adult Participant’s family. Consider the potential implications this would have for the Adult Participant’s health status.

Original Date:

Dates Revised:

enter text.

enter text.

enter text.

enter text.

HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Initials:

Race/Ethnicity:

☐M ☒

Age

Occupation: Student

Marital status:

☒ Single ☐ Partnered ☐ Married ☐ Separated ☐ Divorced ☐ Widowed

Reason for visit: Physical assessment

Perception of health:enter text.

Date of last physical exam:

8/22/2018

Source of information: enter text.

Reason for seeking care: Physical Assessment

Present health or history of present illness:

P

enter text.

Q

enter text.

R

enter text.

S

enter text.

T

enter text.

PERSONAL HEALTH HISTORY/Past health

Childhood illness:

◻ Measles ◻ Mumps ◻ Rubella ◻ Chickenpox ◻ Rheumatic Fever ◻ Polio

Immunizations and dates:

☒Tetanus

Up to date

☒Pneumonia

Up to date

☒Hepatitis

Up to date

☒Chickenpox

Up to date

☒Influenza

Up to date

☒MMR Measles, Mumps, Rubella

Up to date

List any medical problems that other doctors have diagnosed

N/A

Surgeries

Year

Reason

Hospital

N/A

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

Other hospitalizations

Year

Reason

Hospital

N/A

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

Have you ever had a blood transfusion?

☐

Yes

☒

No

Please turn to next page

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Name the Drug

Strength

Frequency Taken and Reason

Claritin

enter text.

1 or 3 times per week

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

enter text.

Allergies to medications, latex, food, iodine/betadine

Name the Drug

Reaction You Had

N/A

enter text.

enter text.

enter text.

enter text.

enter text.

HEALTH HABITS AND PERSONAL SAFETY

All questions contained in this questionnaire are optional and will be kept strictly confidential.

Exercise

☐Sedentary (No exercise)

☐Mild exercise (i.e., climb stairs, walk 3 blocks, golf)

☐Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)

☒Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)

Diet

Are you dieting?

☐

Yes

☒

No

If yes, are you on a physician prescribed medical diet?

☐

Yes

☐

No

# of meals you eat in an average day? Click or tap here to enter text.

Rank salt intake

☐Hi

☐Med

enter text.Low

Rank fat intake

☐Hi

☐Med

enter text.Low

Caffeine

◻ None

☒Coffee

☐Tea

Coke Cola

# of cups/cans per day? 1 cup/day

Alcohol

Do you drink alcohol?

☒

Yes

☐

No

If yes, what kind? Beer

How many drinks per week? 1 per week

Are you concerned about the amount you drink?

☐

Yes

☒

No

Have you considered stopping?

☐

Yes

☒

No

Have you ever experienced blackouts?

☐

Yes

☒

No

Are you prone to “binge” drinking?

☐

Yes

☒

No

Do you drive after drinking?

☐

Yes

☒

No

Tobacco

Do you use tobacco?

☐

Yes

☒

No

☐Cigarettes – pks./day enter text.o

☐Chew - #/day enter text.

☐Pipe - #/day enter text.

☐Cigars - #/day enter text.

☐ # of years enter text.

☐Or year quit enter text.

Drugs

Do you currently use recreational or street drugs?

☐

Yes

☒

No

Have you ever given yourself street drugs with a needle?

☐

Yes

☒

No

Sex

Are you sexually active?

☒

Yes

☐

No

If yes, are you trying for a pregnancy?

☐

Yes

☒

No

If not trying for a pregnancy list contraceptive or barrier method used: birth control

Any discomfort with intercourse?

☐

Yes

☒

No

Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?

☐

Yes

☒

No

Personal Safety

Do you live alone?

☐

Yes

☒

No

Do you have frequent falls?

☐

Yes

☒

No

Do you have vision or hearing loss?

☒

Yes

☐

No

Do you have an Advance Directive and/or Living Will?

☐

Yes

☒

No

Would you like information on the preparation of these?

☐

Yes

☒

No

Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?

☐

Yes

☒

No

FAMILY HEALTH HISTORY

Age

Significant Health Problems

Age

Significant Health Problems

Father

60

Arthritis

Children

☐M ☐ F

N/A

Mother

56

N/A

☐M ☐ F

N/A

Sibling

☒M 23 years old ☐ F

N/A

☐M ☐ F

N/A

☐M ☐ F

N/A

☐M ☐ F

N/A

☐M ☐ F

N/A

Grandmother

Maternal

passed from Stomach cancer in 1978

☐M ☐ F

N/A

Grandfather

Maternal

enter text.

unknown

☐ M ☐ F

N/A

Grandmother

Paternal

enter text.

passed from aneurysm in 1980

☐M ☐ F

N/A

Grandfather

Paternal

enter text.

passed from lymphoma and lung cancer in 1984

MENTAL HEALTH

Comments

Is stress a major problem for you?

☐

Yes

☐

No

Do you feel depressed?

☐

Yes

☐

No

Do you panic when stressed?

☐

Yes

☐

No

Do you have problems with eating or your appetite?

☐

Yes

☐

No

Do you cry frequently?

☐

Yes

☐

No

Have you ever attempted suicide?

☐

Yes

☐

No

Have you ever seriously thought about hurting yourself?

☐

Yes

☐

No

Do you have trouble sleeping?

☐

Yes

☐

No

Have you ever been to a counselor?

☐

Yes

☐

No

WOMEN ONLY

Age at onset of menstruation: 12.

Date of last menstruation: May 15, 2019

Period every 28 days

Heavy periods, irregularity, spotting, pain, or discharge?

☐

Yes

☐

No

Number of pregnancies enter text. Number of live births enter text.

Are you pregnant or breastfeeding?

☐

Yes

☐

No

Have you had a D&C, hysterectomy, or Cesarean?

☐

Yes

☐

No

Any urinary tract, bladder, or kidney infections within the last year? UTI

☐

Yes

☐

No

Any blood in your urine?

☐

Yes

☐

No

Any problems with control of urination?

☐

Yes

☐

No

Any hot flashes or sweating at night?

☐

Yes

☐

No

Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?

☐

Yes

☐

No

Experienced any recent breast tenderness, lumps, or nipple discharge?

☐

Yes

☐

No

Date of last pap and rectal exam? 2017.

MEN ONLY

Do you usually get up to urinate during the night?

☐

Yes

☐

No

If yes, # of times enter text.

Do you feel pain or burning with urination?

☐

Yes

☐

No

Any blood in your urine?

☐

Yes

☐

No

Do you feel burning discharge from penis?

☐

Yes

☐

No

Has the force of your urination decreased?

☐

Yes

☐

No

Have you had any kidney, bladder, or prostate infections within the last 12 months?

☐

Yes

☐

No

Do you have any problems emptying your bladder completely?

☐

Yes

☐

No

Any difficulty with erection or ejaculation?

☐

Yes

☐

No

Any testicle pain or swelling?

☐

Yes

☐

No

Date of last prostate and rectal exam? enter text.

review of systems

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.

☐

Skin/Hair/Nails enter text.

☐

Respiratory enter text.

☐

Neurologic enter text.

☐

Head/Neck enter text.

☐

Cardiovascular enter text.

☐

Recent changes in Weight enter text.

☐

Eyes Bilateral Myopia and Astigmstism

☐

Peripheral Vascular enter text.

☐

Recent changes in Energy level enter text.

☐

Ears enter text.

☐

Gastrointestinal enter text.

☐

Sleep/rest pattern enter text.

☐

Nose enter text.

☐

Urinary UTI

☐

Other pain/discomfort: enter text.

☐

Mouth/Throat enter text.

☐

Musculoskeletal enter text.

1

NR302 Health Assessment I

RUA: Health History Guidelines

NR302 Health History Guidelines V3.docx Revised: 04/2019

11

Purpose Before any nursing plan of care or intervention can be implemented or evaluated, the nurse assesses the individual through the collection of both subjective and objective data. The data collected are used to determine areas of need or problems to be addressed by the nursing care plan. This assignment will focus on collecting subjective assessment data, synthesizing the data, and on identifying health/wellness priorities based on the findings. The purpose of the assignment is two-fold:

 To recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual, and

developmental) affecting health and wellness.

 To reflect on the interactive process between self and client when conducting a health assessment.

Course Outcomes: This assignment enables the student to meet the following course outcomes:

CO1. Explain expected client behaviors while differentiating between normal findings, variations, and abnormalities. (PO1)

CO2. Utilize prior knowledge of theories and principles of nursing and related disciplines to integrate clinical judgment in professional decision-making and implementation of nursing process while obtaining a physical assessment. (PO 4, 8)

CO3. Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1)

CO4. Utilize effective communication when performing a health assessment. (PO 3) CO6. Identify teaching/learning needs from the health history of an individual. (PO 2, 3) CO7. Explore the professional responsibilities involved in conducting a comprehensive health assessment and

providing appropriate documentation. (PO 6, 7)

Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment.

Total points possible: 100 points

Preparing the assignment A Health History Worksheet that can be used to help you organize the Family Medical History information you will obtain from the Adult Participant is located in the Resources section of the Expand page for Unit 2. The use of this tool is optional. There are three parts to this assignment.

1. Health History Assessment (50 points/50%)

Using the following components of a health history assessment and your textbook for explicit details about each category, complete a health assessment/history on an individual of your choice. The person interviewed must be 18 years of age or older and should NOT be a family member or close friend. The purpose of this restriction is to avoid any tendency to anticipate answers or to influence how the questions are answered. Your goal in choosing an interviewee is to simulate the interaction between you and an individual for whom you would provide care. It is important that you inform the person of your assignment and assure him/her that the information obtained will be kept confidential. Please be sure to avoid the use of any identifiers in preparing the assignment. Health History components to be included:

a) Demographics b) Perception of Health c) Past Medical History d) Family Medical History

2

NR302 Health Assessment I

RUA: Health History Guidelines

NR302 Health History Guidelines V3.docx Revised: 04/2019

21

e) Review of Systems f) Developmental Considerations g) Cultural Considerations h) Psychosocial Considerations i) Collaborative Resources

2. Reflection (40 points/40%) Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to evaluate outcomes. Provide a written reflection that describes your experience with conducting this Health History.

a) Reflect on your interaction with the interviewee holistically.

I. Consider the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process (if needed, refer to your text for a description of therapeutic communication and of the interview process).

b) How did your interaction compare to what you have learned?

c) What went well?

d) What barriers to communication did you experience?

I. How did you overcome them?

II. What will you do to overcome them in the future?

e) Were there unanticipated challenges to the interview?

f) Was there information you wished you had obtained?

g) How will you alter your approach next time?

3. Style and Organization (10 Points/10%) Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired information, and appropriate writing skills. Scoring of your work in written communication is based on proper use of grammar, spelling and how clearly you express your thoughts and reasoning in your writing.

• Grammar and mechanics are free of errors. • Able to verbalize thoughts and reasoning clearly • Use appropriate resources and ideas to support topic

For writing assistance (APA, formatting, or grammar) visit the Citation and Writing Assistance: Writing Papers at CU page in the online library.

NR302 Health Assessment I

RUA: Health History Guidelines

NR302 Health History Guidelines V3.docx Revised: 04/2019

31

Grading Rubric Criteria are met when the student’s application of knowledge within the paper demonstrates achievement of the outcomes for this assignment.

Assignment Section and Required Criteria

(Points possible/% of total points available)

Highest Level of Performance

High Level of Performance

Satisfactory Level of

Performance

Unsatisfactory Level of

Performance

Section not present in

paper

Introduction of Disease (50 points/50%)

50 points 46 points 41 points 25 points 0 points

Required criteria 1. Demographics 2. Perception of Health 3. Past Medical History 4. Family Medical History 5. Review of Systems 6. Developmental Considerations 7. Cultural Considerations 8. Psychosocial Considerations 9. Collaborative Resources

Includes no fewer than 9 requirements for section.

Includes no fewer than 8 requirements for section.

Includes no less than 7 requirement for section.

Present, yet includes no required criteria.

No requirements for this section presented.

Reflection (40 points/40%)

40 points 36 points 33 points 20 points 0 points

Required criteria 1. Reflect on your interaction with the

interviewee holistically. a) Consider the interaction in its entirety:

include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process (if needed, refer to your text for a description of therapeutic communication and of the interview process).

b) How did your interaction compare to what you have learned?

Includes no fewer than 7 requirements for section.

Includes no fewer than 6 requirements for section.

Includes no fewer than 5 requirements for section.

Includes 4 or fewer requirements for section.

No requirements for this section presented.

NR302 Health Assessment I

RUA: Health History Guidelines

NR302 Health History Guidelines V3.docx Revised: 04/2019

41

Assignment Section and Required Criteria

(Points possible/% of total points available)

Highest Level of Performance

High Level of Performance

Satisfactory Level of

Performance

Unsatisfactory Level of

Performance

Section not present in

paper

c) What went well? d) What barriers to communication did you

experience? I. How did you overcome them?

II. What will you do to overcome them in

the future?

e) Were there unanticipated challenges to the

interview?

f) Was there information you wished you had

obtained?

g) How will you alter your approach next

time?

Style and Organization (10 points/10%)

10 points 8 points 4 points 0 points

Required criteria

1. Grammar and mechanics are free of errors.

2. Able to verbalize thoughts and reasoning clearly 3. Use appropriate resources and ideas to support

topic

Includes no fewer than 3 requirements for section.

Includes no fewer than 2 requirements for section.

Includes 1 requirements for section.

No requirements for this section presented.

Total Points Possible = 100 points

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