Patient Health History and Review of Systems

Submit the patient history and the review of systems, focusing on the systems we are studying in this class.

The write up should be a 3-5 page summary in APA format of the findings of the complete history and review of systems. Use the headings Patient History, Review of Systems. You should also use subheadings as in the Bickley text. For example, under history, you should use subheadings of Health History, Chief Complaint, etc. The “Case of Mrs. N” in our Bickley text (p. 17-20) gives an excellent example to use as a reference for this assignment.

You will find the “Recording Your Findings” section at the end of each Bickley Chapter very helpful in your documentation for the above assignment. I would suggest using it as your guideline.

Here is a sample paper for your reference:

Sample of Patient Health History and Review of Systems.docxPreview the document

Patient History Form and Rubric

With a patient of your choosing, conduct and document a Patient History, including a Chief Complaint, History of Present Illness, Past Medical and Surgical History, Family History and Personal Social History. (Using the outline in the Bickley textbook, pages 1-2).

Review the Grading Rubric below, which will guide you as you prepare to demonstrate proficiency in your documentation of the Health History.

Patient History Form

Content

Excellent (10 pts.)

Documentation well done with all areas completely discussed from subjective perspective.

Satisfactory (7 pts.)

Documentation missing some areas

Unsatisfactory (0 pts.)

Documentation poor, missing key areas.

Identifying Data

Source of History

Chief Complaint

Present Illness

Medications

Allergies

Past Med Hx

Past Surg Hx

Family Hx

Social Hx

Total Points

              /100

Review of Systems Form and Rubric

Using the same patient, complete a Review of Systems:

Elicit a complete Review of Systems (ROS) (Bickley, pg 4-6).

Demonstrate understanding of the meaning of Pertinent Positives and Negatives.

Accurately document Subjective Abnormal Data.

Demonstrate the components of symptom analysis using The “Seven Attributes of a Symptom.” (Bickley, pg 3)

1. Begin the practice of sequencing and coordinating the Comprehensive Physical Exam of the Adult Patient
2. Identify the anatomical landmarks of the human body of these systems. 7.Correlate examination techniques of the following body systems using the correct sequence and anatomical landmarks in an adult patient.
3. Use correct terminology to record objective components of the physical examination findings.
   Grading Rubric and Form for Comprehensive Review of Systems: You will create your own questions.

Content

Excellent (25 pts.)

Satisfactory (15 pts.)

Unsatisfactory (0 pts.)

History Questions

Appropriate ROS questions in each system area, including documentation of pertinent positives and negatives.

Missing some pertinent ROS or questions.

Lack of understanding of what history questions are appropriate and pertinent for this system or abnormal finding.

Rationale

Appropriate rationale for each history question related to an abnormal finding.

Missing some depth and rationale for history questions related to an abnormal finding.

Lacks understanding and rationale, without explanation of why the questions are pertinent.

Seven Attributes All attributes of the symptoms are evaluated and documented Missing one or two attributes. Lack of understanding of what attributes are and fail to ask appropriate questions.
Write up

Appropriate language, concise, thorough.

Missing some depth or inaccurate language/terminology.

Lacks understanding, detail, and accuracy in language.