Health History and Physical Assessment

 

Assignment Section

(Points Possible/% of Total Points)

Subjective and/or Objective Data
Health History

(30 points/30%)

Subjective Data
1. Demographic data  
2. Reason for care (why they are in the facility)  
3. Present illness (PQRST of current illness)  
4. Perception of health  
5. Past medical history (including medications, allergies, and vaccinations and immunizations)  
6. Family medical history  
7. Review of systems  
8. Developmental considerations  
9. Cultural considerations  
10. Psychosocial considerations  
11. Presence or absence of collaborative resources (community, family, groups, and healthcare system)  
Physical Examination

(30 points/30%)

Objective Data
1. HEENT (head, eyes, ears, nose, and throat)  
2. Neck (including thyroid and lymph chains)  
3. Respiratory system  
4. Cardiovascular system  
5. Neurological system  
6. Gastrointestinal system  
7. Musculoskeletal system  
Needs Assessment

(20 points/20%)

 
1. Based on the health history and physical examination findings, determine at least two health education needs for the individual. Remember, you may identify an educational topic that is focused on wellness.  
2. Support the identified health teaching needs selected with evidence from two current, peer-reviewed journal articles.  
3. Discuss how the interrelationships of physiological, developmental, cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health education.  
4. Describe how the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) effect proposed teaching.  
Reflection

(10 points/10%)

 
1. Describe 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.  
2. How did your interaction compare to what you have learned?  
3. What went well?  
4. What barriers to communication did you experience?  
5. How did you overcome them?  
6. What will you do to overcome them in the future?  
7. Were there unanticipated challenges to the interview?  
8. Was there information you wished you had obtained?  
9. How will you alter your approach next time?