MN552 Advanced Health Assessment Unit 2 Documenting Subjective information

MN552 Advanced Health Assessment Unit 2 Documenting Subjective information

MN552 Advanced Health Assessment Documenting Subjective information

History and Interview

Please select a volunteer friend or family member to interview and gather data to complete this Assignment. The following guide will assist you in gathering subjective data in an organized, systematic manner to prevent omission of important components of the health history.

Date of History/Interview:

Source of history and Reliability:

 Biographical Data

1. Name (use initials only)
2. Primary language
3. Age and Date of Birth
4. Place of Birth
5. Gender
6. Race
7. Marital Status
8. Ethnic/Cultural Origin
9. Education ( highest level completed)
10. Occupation/Professional
11. Health insurance (ie commercial, state, federal)
12. Chief Complaint (reason for seeking health care):
    1. Brief spontaneous statement in client’s own words
    2. Includes when the problem started ( “chest pain for 2 hours”)

3. History of Present Illness: A well organized, chronological record of client’s reason for seeking care, from time of onset to present. Please include the 8 critical characteristics using the OLD CARTS

 P – Provocative or palliative (What brings it on? What makes it better or worse?)

Q – Quality or quantity (Describe the character and location of the symptoms; How does it look, feel, sound?)

R – Region or radiation (Where is it? Does the symptom radiate to other areas of the body?).

S – Severity (Ask the patient to quantify the symptom(s) on a scale of 0-10).

T – Timing (Inquire about time of onset, duration, frequency, etc.)

U – Understand Patient’s Perception of the problem (What do you think it means?)

          ** Put all of that information into the heading HPI in a story format.

4. Past Medical History (list down not across)
   1. Medical Hx: major illnesses during life span, injuries, hospitalizations, transfusions, and disabilities
   2. Childhood Illnesses: Measles, mumps, rubella, chickenpox, pertussis, strep throat
   3. Surgical Hx; procedures, dates, inpatient or outpatient
   4. Obstetric HX: Number of pregnancies, term deliveries, preterm births, abortions

(spontaneous or induced), number of children living

1. Immunizations
2. Psychiatric Hx: childhood and adult (treated or hx of)
3. Allergies: Medications, food, inhalants or other (what occurs with reaction)
4. Current Medications: Include all prescription, herbal/supplements and OTC, dosage, frequency
5. Last Examination Date: Physical, eye exam, foot exam, dental exam, hearing screen, EKG, chest X-Ray, Pap test, mammogram, serum cholesterol, stool occult blood, prostate, PSA, UA, TB skin test; other health maintenance tests for infants/children may include sickle-cell, PKU, lead level, and hematocrit
6. Family History list FHx
   1. Include parents, grandparents, spouse, and children.
   2. Health conditions, familial and communicable diseases/illnesses
   3. Note whether family member deceased or living
   4. Life style patterns
   5. Immigrant status
   6. Spiritual resources/religion
   7. Health perception
   8. Nutritional patterns: Appetite (any changes); satisfaction with current weight; gains or losses; recall of usual intake; any cultural restrictions/intolerances; amount of fluid per day and type
   9. Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinence
   10. Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxins
   11. Occupational health: Known exposure to environmental toxins at work
   12. Functional assessment: ADLs, IADLs, interpersonal relationships/resources (see page 57 in Jarvis textbook)
   13. Role and family relationships: Immediate family composition; how are family decisions made; impact of family member’s health on family
   14. Cognitive function: Memory; speech; judgment; senses
   15. Rest/sleep patterns: Number of hours; naps; number of pillows; any aids for sleep
   16. Exercise patterns: Type and frequency
   17. Hobbies/recreation: Leisure activities; any travel outside of the US
   18. Social habits: Tobacco; alcohol; street drug use
   19. Intimate partner violence (review screening questions on page 58 in the Jarvis textbook)
   20. Coping/stress management: Any major life change in past 2 years; do you feel tense; source; what helps
   21. Sexual patterns: Are you sexually active; gender preference; has anything changed about your sexual health/function

III. Review of Symptoms

Objective:

Assessment: Please list your diagnosis first then your differentials. Rule in and rule out diagnosis and differentials.

1.

2.

3.

4.

Plan:

1.

2.

3.

4

ADDITIONAL INSTRUCTIONS FOR THE CLASS – MN552 Advanced Health Assessment Unit 2 Documenting Subjective information

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• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses. MN552 Advanced Health Assessment Unit 2 Documenting Subjective information

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. MN552 Advanced Health Assessment Unit 2 Documenting Subjective information

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. MN552 Advanced Health Assessment Unit 2 Documenting Subjective information

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. MN552 Advanced Health Assessment Unit 2 Documenting Subjective information

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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