Case- Study: Performing a Health Assessment

Case- Study: Performing a Health Assessment
Case- Study: Performing a Health Assessment
Case- Study: Performing a Health Assessment
NR305 Week 4 Course Project Milestone 1 Latest 2017 November Course Project Milestone 1: Health History Guidelines Updated 9/22/2017 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. Directions Find an adult who is not related to you who is willing to let you take a health history. Download the NR305_Milestone1_Form (Links to an external site.)Links to an external site.. 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. 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. 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.