The History and Interviewing Process
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
The History and Interviewing Process
1-2
Student Checklist
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Ball: Seidel’s Guide to Physical Examination, 8th Edition
Chapter 0 1 : The History and Interviewing Process
Student Checklist
Health History Guide
Assessed Appropriately by Student?
Yes
No
Comments
- Beginning data
- Date and time
- Source of data (patient, family member, etc.)
- Name of interviewer and role (i.e., student nurse)
- Patient’s identifying information and biographic data (cultural background, family structure, education, and economic and environmental data may be listed in the personal and social history section.)
- Name
- Gender
- Age
- Birth date and place
- Race and culture
- Religion
- Education
- Marital status
- Occupation
- Address and phone number
- Socioeconomic data (income, members of household, means of transportation, etc.)
- Other (source of referral, previous health care provider)
III. Present illness
- Chief concern (CC)
- Symptoms (nature, course, location, and pattern of problem)
- Date and timing (gradual or sudden onset, duration, frequency)
- Character, quality, quantity, and location (generalized or radiating pain)
- Associated events (setting)
- Treatments (remissions)
- Effect on other systems (appetite)
- Influence on usual activities (sleep)
- Other (coping ability)
- Medical history
- Overall health before the presenting problem
- Previous hospitalizations and illnesses/dates
- Surgeries/dates
- Serious injuries and disabilities/dates
- Major childhood illnesses/dates
- Major adult illnesses/dates
- Other pertinent data
- Previous health care
- Recent health examination (physical, Pap smear, x-rays, TB test, dental, vision, hearing)
- Immunizations (polio, diphtheria, tetanus, hepatitis B, influenza, mumps, rubella, pertussis, pneumovax, measles, varicella)
- Skin tests (BCG/PPD)
- Other (obstetric care, screening tests, laboratory work)
- Current health/risk factors
- Exercise (how often, duration)
- Smoking (how much per day)
- Alcohol (how often, amount, type)
- Nutrition (caffeine, salt intake, amount)
- Sleep pattern (number of hours /night)
- Other (work stress, anxiety)
- Medication data
- OTC drugs (including vitamins)
- Prescriptions (dosage, schedule, including birth control pills)
- Allergies (transfusions, seasonal or environmental, food, dyes)
- Other (illegal drug use)
- Family history
- Status of family members
- Family tree (narrative, genogram, pedigree)
- Major health conditions (heart disease, high blood pressure, cancer, tuberculosis, stroke, sickle cell disease, cystic fibrosis, epilepsy, diabetes, gout, kidney disease, thyroid disease, asthma or other allergic condition, forms of arthritis, blood diseases, sexually transmitted infections, familial hearing, and visual or other sensory problems)
- Genetic disorders (sickle cell disease)
- Personal and social history
If not addressed previously or if more information is needed, describe cultural background, family structure, stress factors, educational data, economic status, and environmental data (home, school, work, “typical day”)
VII. Review of physiologic systems
- General, overall trends
- Vital signs (temperature, pulse [apical and radial], blood pressure, and respirations)
- Previous measurements (height and weight; head, chest, limb circumferences)
- Usual health status (fatigue or fever patterns)
- Other (recent change in usual condition)
- Nutritional status
- Usual diet (hour-by-hour diary)
- Appetite trends
- Food choices (preference foods)
- Skin, hair, and nails
- Usual condition of skin, hair, and nails
- Previous diseases or problems (rash or eruption, itching, pigmentation or texture change, excessive sweating, abnormal nail or hair growth)
- New or recurrent conditions
- Lymphatic system
- Usual condition of lymphatic system (i.e., presence of lymphedema)
- Previous lumps or nodules (neck or groin area associated with an infection)
- Other (lymph node enlargement, tenderness, suppuration)
- Head and neck
- Usual condition of head and neck
- Previous diseases or problems (headaches, dizziness, syncope, trauma)
- New or recurrent conditions
- Eyes
- Usual condition of eyes, any discharge
- Previous diseases, problems (glaucoma or trauma)
- New or recurrent conditions
- Ears, nose, and throat
- Usual condition of ears, nose, and throat
- Previous diseases, problems (tinnitus, vertigo, infections, or surgeries)
- New or recurrent conditions (nasal polyps, hearing loss)
- Other (associated allergies, condition of mouth and teeth)
- Chest and lungs
- Usual condition of respiratory system
- Previous disease or problems (cough, shortness of breath, infections)
- New or recurrent conditions (pain related to respiration)
- Other (last chest x-ray)
- Heart and blood vessels
- Usual condition of cardiovascular system
- Previous diseases and problems (chest pain or distress, palpitations, dyspnea, edema, hypertension, previous myocardial infarction)
- New or recurrent conditions (chest pain, orthopnea)
- Other (last ECG)
- Breasts
- Usual condition of breasts
- Previous diseases, problems (pain, tenderness, discharge, lumps, galactorrhea)
- New or recurrent conditions (tenderness, new lump or nodule)
- Other (last mammogram/date, breast self-awareness, breast self-examination)
- Gastrointestinal
- Usual condition of alimentary tract (appetite, digestion)
- Previous diseases or problems (ulcers, dysphagia, heartburn, nausea, vomiting, hematemesis, flatulence, constipation, diarrhea, hemorrhoids, jaundice, gallstones, polyps, tumor)
- New or recurrent conditions (abdominal pain, change in stool color or contents)
- Other (previous diagnostic imaging)
- Genitourinary (female)
- Usual condition of genitourinary system (including menstruation)
- Previous diseases or problems (lesions, sexually transmitted diseases, pain, discharges)
- New or recurrent conditions (irregular menses)
- Other (sexual and childbearing history)
- Genitourinary (male)
- Usual condition of genitalia (erections and ejaculation data)
- Previous diseases or problems (infertility)
- Endocrine
- Usual condition of endocrine system
- Previous diseases or problems (diabetes)
- New or recurrent conditions (thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change, polydipsia, polyuria, changes in facial or body hair, skin striae)
- Other (changes in facial or body hair, increased hat and glove size)
- Musculoskeletal system
- Usual condition of musculoskeletal system (gait)
- Previous diseases or problems (joint stiffness, restriction of motion)
- New or recurrent conditions (pain, swelling, redness, heat)
- Other (deformities; limitations; use of devices, e.g., canes, walkers)
- Neurologic system
- Usual condition of central nervous system
- Previous diseases or problems (seizures, tremors, tingling sensations)
- New or recurrent conditions (loss of memory, weakness or paralysis)
- Other (previous motor, sensory, and cognitive test results)
- Physiologic symptoms
- Usual mental and psychologic abilities
- Previous diseases or problems
- New or recurrent conditions
- Other (symptoms of Alzheimer disease)
- Cross-system data
- Data that depict endocrine changes (symptoms that may suggest thyroid disease or diabetes)
NOTE: This outline can be used as a guide for recording findings related to a patient’s age and condition.
Add data that are pertinent to the patient and omit the parts of the outline that are not applicable.
RUBRIC
QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points: Student failed to submit the final paper. 20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. 40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. 50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points: Student failed to submit the final paper. 5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors 10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points: Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. GET THIS PROJECT NOW BY CLICKING ON THIS LINK TO PLACE THE ORDER
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