Nursing: History & Physical Assignment
Nursing: History & Physical Assignment
Nursing: History & Physical Assignment
For this paper, you do not need to follow any particular format and you do not need to include references as HIPAA would forbid referencing the subject. However, follow these guidelines:
Typed, double spaced using Word (Office 2007 or 2010)
Include your name on it
Use headings as appropriate(see below) and format them uniformly throughout the paper.
Use correct spellings and grammar; the majority of the assignment grade will be based on the content covered, but points will be deducted for misspellings and grammatical errors.
Refer to the HIPAA rules listed in the syllabus for information to omit. If you have a question about including any piece of information, contact the course instructor.
Submit the completed assignment as a file upload through the Canvas Assignments tool.
Refer to the attached document for specific assignment guidelines and components to be addressed, and the attached rubric for grading specifics.
Canvas will alert me when the assignment is submitted, and will show you a confirmation of submission. I will provide individual feedback on each paper.
Supporting Materials
ADULT HEALTH HISTORY 9
This is how the Running head should appear on page 1, it is different on all other pages please review. Please remember the running head after the colon cannot be more than 50 characters, including spaces. Your title in the running head may be shortened due to this.
Adult Health History
First and Last Name
Indiana University Southeast
Adult Health History
This documentation is a comprehensive health history of TJ, a 45 year old male who lives
in Indiana. TJ has been married for 25 years. He and his wife have two daughters who are 21
and 22. The oldest daughter has a masters in elementary education and teaches in the Greater
Clark school corporation. She has been married for two years and she and her husband are
expecting their first child in May. The youngest daughter is finishing her senior year of nursing
school at the University of Louisville. TJ denied having any cultural, religious or spiritual values
that would inhibit him from participating in this interview. TJ denies any exposure to domestic
partner violence or sexual abuse. The interview took place in TJs living room. The setting was
very nice, quiet, comfortable, and free from distractions.
Present Health/History of Present Problem(s )
TJ reports no present health issues.
.
Past Health
Childhood illnesses
TJ denies having measles, mumps, or rubella (MMR ), and pertussis. He did report
having chicken pox at age six. Many episodes of strep throat (denies knowledge of rheumatic
fever), tonsillectomy at age nine.
Accidents or injuries
Bike wreck in third grade, broken collar bone and pulled growth center from humerous.
Laid in traction for three weeks at hospital. Doctor was not sure if damage to growth plate would
cause long term issues. Arm grew at normal rate and size, no problems.
Serious or chronic illnesses
Denies any history of serious or chronic illnesses.
Rubric
Complete Adult Health History
Complete Adult Health History
Criteria Ratings Pts
Introductory Paragraph
Exceeds Standard
5.0 pts
Meets Standard
4.0 pts
Below Standard
3.0 pts
No Marks
0.0 pts
5.0 pts
Present Health/History of Present Problems(s)
Exceeds Standard
5.0 pts
Meets Standard
4.0 pts
Below Standard
3.0 pts
No Marks
0.0 pts
5.0 pts
Past Health
Exceeds Standard
15.0 pts
Meets Standard
12.0 pts
Below Standard
10.0 pts
No Marks
0.0 pts
15.0 pts
Family History
Exceeds Standard
15.0 pts
Meets Standard
12.0 pts
Below Standard
10.0 pts
No Marks
0.0 pts
15.0 pts
Review of Systems
Exceeds Standard
15.0 pts
Meets Standard
12.0 pts
Below Standard
10.0 pts
No Marks
0.0 pts
15.0 pts
Functional, personal and social history
Exceeds Standard
15.0 pts
Meets Standard
12.0 pts
Below Standard
10.0 pts
No Marks
0.0 pts
15.0 pts
Conclusion
Exceeds Standard
5.0 pts
Meets Standard
4.0 pts
Below Standard
3.0 pts
No Marks
0.0 pts
5.0 pts
Reflection
Exceeds Standard
15.0 pts
Meets Standard
12.0 pts
Below Standard
10.0 pts
No Marks
0.0 pts
15.0 pts
Writing
Exceeds Standard
10.0 pts
Meets Standard
9.0 pts
Below Standard
8.0 pts
No Marks
0.0 p
