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Students will demonstrate knowledge of interviewing skills, the components of a health history, recording the history data, and assigning three priorities

February 5, 2024

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 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. I-ncludes 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 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

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