Course Project Milestone 1: Health History Guidelines

Purpose

The student will obtain a health history on a willing, nonrelated, adult participant in order to generate written documentation that is clear and accurate. Note: Failing to complete this assignment using an adult participant other than yourself will result in a 20% penalty deduction being applied.

Course Outcomes

This assignment enables the student to meet the following Course Outcomes.

CO #3: Utilize effective communication when performing a health assessment. (PO #3)

CO #4: Identify teaching/learning needs from the health history of an individual. (PO #2)

CO #5: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO #6)

Points

This assignment is worth a total of 225 points.

Due Date

The Course Project Milestone 1: Health History assignment is to be submitted by Sunday, 11:59 p.m. MT at the end of Week 4. Post questions to the Q & A Forum. Contact your instructor if you need additional assistance.

Disclaimer

The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do not need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.” If the client fails to disclose answers to several items, you will need to find another client who is willing to share.

You are required to use the assignment specific item(s) (article/systematic review/topic/form/templates) or you will earn a “0” for the assignment. In addition, assignments that do not follow the current guidelines or use the required item, as defined above, will be evaluated for evidence of an academic integrity violation.

After the due date, there will be no opportunity for revision or resubmission of assignments that have been uploaded to the submission area. This includes blank, incomplete, incorrect file, and/or incorrect file format documents. It is your responsibility to submit the correct completed assignment in the correct format to the correct submission area. Your last submission before the due date will be graded. You may not resubmit after the due date with a different file and incur a late deduction per the Late Assignment policy.

Directions

Find an adult who is not related to you who is willing to let you take a health history.
Download the required NR305_Milestone1_Form You will type your answers directly into this Word document. Your paper does not need to follow APA formatting; however, you are expected to be clear in your communication by using correct medical terminology, grammar, and spelling.
You are required to complete the form using the productivity tools required by Chamberlain University, which is Microsoft Office Word 2013 (or later version), or Windows and Office 2011 (or later version) for MAC. You must save the file in the “.docx” format. Do NOT save as Word Pad. A later version of the productivity tool includes Office 365, which is available to Chamberlain students for FREE by downloading from the student portal at http://my.chamberlain.edu Click on the envelope at the top of the page.
Review the examples in Chapter 4 of your textbook to gain insight into how to document the health history. Remember this is a health history, not a physical examination. Avoid words like frequently, improved, increased, decreased, good, poor, normal, or WNL as they may have different meanings for different people. Instead, document the specific data that led you to these conclusions, for example, 3x/day instead of frequently, or consuming four servings of vegetables/day instead of increased vegetable servings.
Save the file by clicking Save as and adding your last name to the file name, for example, NR305_Milestone1_Form_Smith. You must save as a .docx file, but do not save as a “Word Pad” document.
Submit the completed form by Sunday, 11:59 p.m. MT at the end of Week 4.
Please post questions in the Q & A Forum so the entire class may view the answers.

Solution:

BIOGRAPHICAL DATA (15 points)
Date:	5/24/2018
Initials:	AG
Age:	61
Date of birth:	05/05/1957
Birthplace:	Kingston Jamaica
Gender:	Female
Marital status:	Single
Race:	Black
Religion:	Christianity
Occupation:	Home Health Aide
Health insurance:	Health Plus
Source of information:	Patient
Reliability of source of information:	Alert and oriented to time, place and person
PRESENT HEALTH HISTORY/ILLNESS (20 points)
Reason for seeking care:	Regular scheduled check up
Health patterns:	Diabetic for the past 41 years
Health goals:	Patient wants to stay active and keeps A1C Levels below 7% she is trying to eat healthy and do daily walks.
HEALTH BELIEFS AND PRACTICES (15 points)
Beliefs and practices:	Patient is a Christian and says prayer is her source of strength. She also states that she tries to eat right, and her sister tries to accommodate her by eating the things that she eats also.
Factors influencing healthcare decisions:	The patient also believes in herbal medication, she states that she has friends and family taking the moringa and they are doing well. She also refers to a friend who has been been diabetic and his doctors says his A1C has been below 7 for the past 10 years.
Related traits, habits or acts:	She drinks Moringa tea and says it helps her maintain her blood sugar levels.
MEDICATIONS (20 points) (Please refer to your assignment guidelines.)

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