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.
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
