Approach to Clinical Nursing and the Health History

Overview and Outcomes

The health history is the patient’s health story in his/her own words. It gives not only insight into the patient’s status at the present time, but a view of the events leading up to the present situation. The nurse is able to get a wide-angle view so to speak about the person’s health, while the physical examination gives a picture of health status at just this moment in time. The history gives the examiner clues as to where to focus the physical examination more thoroughly. It is said that a skilled interviewer often needs the physical examination only to confirm the findings of the history. Both the history and physical examination are extremely important parts of the same assessment process.

Communication skills play an important role in history taking. Although it seems like history taking is merely the asking of questions, frequently these questions are about very personal and private matters. Often the patient might not see the relevance of the questions to his/her current health problems. Cultural beliefs might be a barrier to disclosure of certain information. In order to get the needed information, questioning must be conducted in a tactful and respectful manner. Trust must be established in order to allow the patient to reveal the sensitive information that might be related to a health problem. This trust must be established often in a very short period of time. It is a challenge.

After completing this unit, you should be able to:

• Collect subjective patient history data.
• Discuss the comprehensive physical and functional health history.
• Document patient history data.
• Examine patient interviewing approaches.
• Differentiate among the various elements of a comprehensive holistic health assessment.
• Apply principles of symptom analysis.

Course outcome(s) practiced in this unit:

NU333-1: Analyze the various elements of a comprehensive holistic health assessment and history.

Assignment Details

This week you will complete one Shadow Health Assignment:

• Shadow Health: Health History

Health History Assignment

1. This Shadow Health Assignment requires you to collect health history data from the patient, Tina Jones. You will interview, educate, empathize, and participate in a care plan activity.You will document the history data in proper format as described in Chapter 4 of your text. Be sure to include each of the categories of information, in your documentation, as described in Chapter 4 of your text.
   • Biographic Data
   • Source of History
   • Reason for Seeking Care/Chief Complaint
   • History of Present Illness
   • Past Health
   • Family History
   • Review of Systems
   • Functional Assessment (Including Activities of Daily Living)
   • Perception of Health
   Click the link to access a document to help you with the documentation sections in Shadow Health.
2. Progress notes are an important part of our patient documentation record and should be completed with each Shadow Health Assignment. There is a section in the EHR (Electronic Health Record) where you can chart this progress note.
3. To begin this Assignment, open Shadow Health from the Course Resources, select your Shadow Health course and select Health History. You will be able to re-open your assessment after the first complete attempt so you can improve your score by asking more questions and performing additional assessments. You do not have to start a second attempt from scratch.Making Corrections to Your Assignment
   1. You will be able to reopen your completed attempts to make corrections and improve your score.
   2. You DO NOT have to start these assignments from scratch
   3. You can reopen these assignments to make corrections from the Assignment Overview or Assignment Results page by following these steps – https://link.shadowhealth.com/reopening.
   4. Make sure to “Turn In” your assessment by the end of the unit by following these steps – https://link.shadowhealth.com/Turn-In-Attempt.
   If you have any technical issues during the assignment please contact the Shadow Health Support Team –
   http://link.shadowhealth.com/support.
4. When you are ready to submit your Assignment, click on this unit’s Dropbox link then click on Add Attachments. Then click on Upload and attach a Word Document with your note of completion to notify your professor that the Assignment has been completed. Your note of completion should include Dear Prof. XXX I have completed the Unit 2 Shadow Health assignment and marked it for grading in Shadow Health. Thank you. Make sure to use the naming criteria when saving your document.
5. Submit your work before midnight on the last day of the unit.

To view the grading rubric for this Assignment, please visit Grading Rubrics under Course Resources.

When you are ready to submit your Assignment, click the Dropbox, then attach your file. Make sure to save a copy of your work and be sure to confirm that your file uploaded correctly.

Shadow Health Technical Support:

If at any time you have any questions or encounter any technical issues, please visit the Shadow Health Learner Support page at http://link.shadowhealth.com/support for contact information and hours.

Submit your Assignment to the unit Dropbox before midnight on the last day of the unit.

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