Health History

Purpose The student will obtain a health history on a willing, non-related, adult participant in order to generate written documentation that is clear and accurate. 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 175 points. Due Date The Course Project Milestone 1: Health History assignment is to be submitted to the Dropbox by Sunday, 11:59 p.m. MT at the end of this Week 4. The guidelines and grading rubric may be found in Doc Sharing. 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.” Directions 1. Find an adult who is not related to you who is willing to let you take a health history. 2. Download the NR305_Milestone1_Form from Doc Sharing. 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. 3. Review the examples in Chapter 10 of your textbook to gain insight into how to document the health history. 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, e.g., 3x/day instead of “frequently,” or consuming 4 servings of vegetables/day instead of “increased” vegetable servings.

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