Health History Documentation Essay

Grading of the Health History is based on complete, comprehensive and concise documentation. This assignment has two sections to it. Once you complete the health history you will accurately document the information based on the guidelines. The second section of the paper is your reflection of the experience. Spelling must be accurate and the correct terminology must be utilized. Health History Documentation Essay The assignment must be turned in on time. The assignment is worth 30% of final grade. The documentation including the reflection paper must be typed and well-thought. Documentation Section: This section includes concise and accurate documentation of the health history data. It is written in a narrative format. Utilize the rubric to provide guidance.Health History Documentation

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You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.Health History Documentation Essay

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.Health History Documentation Essay

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument. Health History Documentation Essay

Collection and Documentation of Health History
Purpose of Health record
Health history or health record is a systematically created document which stores the complete history of the diseases and physical conditions of the patient. This document gives a chance to the physicians to understand the complete background of patient’s physical health and helps them to plan their further strategy for the treatment of the patient.
This document also provides an opportunity to educate medical students and to provide data for medical research (Makoul, 2003). Health history is the first and foremost part of any medical examination. This data helps the physician to understand the physiological, psychological and sociological problems of the patient and gives a clue to the physicians for their treatment (Desmond & Copeland, 2000).
Components of Effective Health History
The complete medical history, with slight variations, may consists of:Health History Documentation Essay
• Biographical data: it consists of information regarding patient’s personal life. It helps to determine the cultural background of the patient through which the physician can identify any specific need and belief that may affect the health of the patient. The information regarding patient’s education and status helps to determine his strengths and weaknesses and the factors which may affect his / her health. For example if a patient holds a high profile position, maybe the stress of the job is the major cause of the disease etc.

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A guide to taking a patient’s health history is an article published in Nursing Standard in the August 2007 issue, written by Hiliary Lloyd and Stephen Craig. In this article Lloyd and Craig outlines the process and rationale for taking a health history. Also, this article provides different methods to taking a comprehensive history.Health History Documentation Essay

Summary of Article
Taking a successful history includes preparing the environment, effective communication skills, and order. It is the most important part of patient assessment. In the process, patients are able to present vital information about their problem in their own words. To explore a decline in a patient’s health requires a careful evaluation of patient needs.
To avoid receiving…show more content…
Examples include, maintaining eye contact, showing interest by posture, using hand and facial gestures, appropriate rate, tone and volume. According to D’Amico & Barbarito, giving full attention to verbal and nonverbal messages is called attending and may be as much as 93% of the message that the client sends. After the introduction, the nurse should obtain the patients consent and determine how the patient prefers to be addressed as well as gather demographic or biographic information including age and occupation, marital status, religion, etc. Another important factor of communication is asking open-ended questions. These enable the nurse to elicit more information from the patient. After which a focused assessment with specific questions can be asked to clarify previously obtained assessment data, gather missing information about a specific health concern, identify or validate possible nursing diagnoses. According to Lloyd and Craig, summarizing the history back to the patient allows the nurse to be sure he or she has the information correct.Health History Documentation Essay

Health assessment thus plays an important role to provide information about one’s health. Assessment is the first step in the nursing process and includes collection, verification, organization, interpretation and documentation of data.(Sue C.DeLaune and Patriciak .Ladner,2011)
Almost every admitted patient the first time required the implementation of the health assessment to determine their health condition to enable healthcare plans and implementation what they need to do.
On way of organizing the information that nurse need to collect is by using a nursing framework .A framework for assessment , the nurse systematically collecting the physical, psychological, socio cultural and different aspects of the activities of …show more content…
The same types of problems can be classified into different types of items such as nutritional state it can be combine with diet of daily habits.

Select one patient (neighbor, family, or friend) and write-up their comprehensive health history. Include the following variables:
Identifying data.
Past medical history.
Health status, perceived barriers, and support.
Chief complaint (CC).
History of present illness (HPI).Health History Documentation Essay
Family and/or social history (PFSH).
Focused review of systems (ROS).
Identify age, spiritual values, and cultural variables that were considered and how these variables influenced your interviews or health history.
In a 1,000-1,250-word essay, summarize effective interview techniques for collecting a patient’s health history. Include the following:
Address how to elicit the patient’s interpretation of their health status, their perceived barriers, and support.
Critique the effectiveness of several history taking techniques with rationale from the readings.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is required.Health History Documentation Essay