HEALTH HISTORY AND ASSESSMENT

HEALTH HISTORY AND ASSESSMENT
June 6, 2019 Off All,

Description

The worksheet has to be filled out. This worksheet is used to assist the student in gathering and organizing information when conducting a health history. Family Member Description Paternal grandfather First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Paternal grandmother First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Father First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Father’s siblings- Summary of any significant health issues Maternal grandfather First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Maternal grandmother First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Mother First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Mother’s siblings- Summary of any significant health issues Adult Participant First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Adult participant’s siblings Summary of any significant health issues Adult participant’s spouse/significant other First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Adult participant’s children- Up to 4 children Child #1 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Child #2 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Child #3 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Child #4 first and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: An example Family Member Description Paternal grandfather First and last initials: RL Birthdate: 1921 Death date: 1981 Occupation: Retired as a coal miner Education: 6th grade Primary language: English Health summary: He was diagnosed with chronic lung disease, diabetes, and hypertension. He died from a heart attack. Paternal grandmother First and last initials: ML Birthdate: 1932 Death date: 1998 Occupation: House wife Education: Does not want to disclose Primary language: English Health summary: Diagnosed with chronic lung disease from smoking cigarettes. Died from heart failure. This example points to common problems among this generation on both sides of the Adult Participant’s family. Consider the potential implications this would have for the Adult Participant’s health status. AFTER THE WORKSHEET IS FILLED OUT THE FOLLOWING QUESTIONS HAS TO BE ANSWERED AND A REFLECTION PAPER. I HAVE PROVIDED AN EXAMPLE ON THE WORKSHEET. Preparing the assignment The Health History Worksheet can be used to help you organize the Family Medical History information you will obtain from the Adult Participant (document link is on the Assignment page). The use of this tool is optional. There are three parts to this assignment. 1. Health History Assessment Using the following components of a health history assessment and your textbook for explicit details about each category, complete a health assessment/history on an individual of your choice. The person interviewed must be 18 years of age or older and should NOT be a family member or close friend. The purpose of this restriction is to avoid any tendency to anticipate answers or to influence how the questions are answered. Your goal in choosing an interviewee is to simulate the interaction between you and an individual for whom you would provide care. It is important that you inform the person of your assignment and assure him/her that the information obtained will be kept confidential. Please be sure to avoid the use of any identifiers in preparing the assignment. Health History components to be included: a) Demographics b) Perception of Health c) Past Medical History d) Family Medical History e) Review of Systems f) Developmental Considerations g) Cultural Considerations h) Psychosocial Considerations i) Collaborative Resources 2. Reflection Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to evaluate outcomes. Provide a written reflection that describes your experience with conducting this Health History. a) Reflect on your interaction with the interviewee holistically. I. Consider the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process (if needed, refer to your text for a description of therapeutic communication and of the interview process). b) How did your interaction compare to what you have learned? c) What went well? d) What barriers to communication did you experience? I. How did you overcome them? II. What will you do to overcome them in the future? e) Were there unanticipated challenges to the interview? f) Was there information you wished you had obtained? g) How will you alter your approach next time?