Health History and Physical Assessment

                                        HealthHistory and Physical Assessment Guidelines (interviewed must be 18 years of ageor older)

Health History: Subjective Data

Required criteria

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: Objective Data

Required criteria

1. From

o HEENT (head, eyes, ears, nose, and throat)

o Neck (including thyroid and lymph chains)

o Respiratory system

o Cardiovascular system

2. From

o Neurological system

o Gastrointestinal system

o Musculoskeletal system

o Peripheral vascular system

Needs Assessment

Required criteria

1. Based on the health history and physical examinationfindings,

determine at least two health education needs for theindividual

Remember, you may identify an educational topic that isfocused

on wellness.

2. Support the identified health teaching needs selectedwith

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 individuals strengths (personal,family, and

friends) and collaborative resources (clinical, community,and

health and wellness resources) effect proposed teaching.

Reflection

1. Describe the interaction in its entirety: include theenvironment,

your approach to the individual, time of day, and otherfeatures

relevant to therapeutic communication and to the interview

process.

2. How did your interaction compare to what you havelearned?

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?

Style and Organization

1. Writing reflects synthesis of information from priorlearning

applied to completion of the assignment.

2. Grammar and mechanics are free of errors.

3. Able to verbalize thoughts and reasoning clearly.

4. Use appropriate resources and ideas to support topic.

5. Adheres to APA 7ed. recommendations for title page,running head,

headings, in-text citations, and reference page.

6. HIPAA protocols followed.