NSG 351 Comprehensive Health History Grading Rubric — Fall 2014 Student Name: Emily Lawler IDENTIFYING DATA: (p. 49-50, Jarvis) This information is tailored to setting. Minimally should include date, name,(always use initials for confidentiality) age, gender, marital status, race, primary language, and source and reliability of information. + Includes date and time of history (1 point) * Identifying data - age, gender, marital or relationship status, occupation, ethnicity/race, primary language, patient initials (1 point for each) ‘+ Source of information (1 point) Reliability of information (consider memory, trust, mood) (1 point) NOTE: No points will be awarded in this section if patient’s full name is written here. 10 10 REASON(S) FOR SEEKING CARE: (p. 50, Jarvis) ‘+ Reason for seeking care/ chief concern is listed ‘+ _Used patient’s own words in quotes PRESENT HEALTH/ HISTORY OF PRESENT ILLNESS (p. 50 Jarvis) (is this section totally inclusive? Has a mnemonic been followed with a very clear understanding of HPI presented?) ‘© Atleast one health concem is present (1 point) ‘+ _ Each of the OLDCART or PORSTU attributes is addressed for EACH chief ‘complaint or symptom (2 points each): © OLDCART - Onset, Location/ radiation, Duration, Characteristic symptoms ~ severity, description, Associated manifestations, Relieving or exacerbating symptoms, Treatment oR © PQRSTU - Provocative or Palliative, Quality or Quantity, Region Radiation, Severity Scale, Timing, Understanding patient's perception. ‘+ Self-treatment (1 point) ‘+ _ Past occurrences (1 point) 7 16 AST HEALTH: (p. 51, Jarvis) (Are all sections addressed? Dates are important in this section as well) NOTE: For each issue or symptom identified below you must list date orage, diagnosis, treatment, complications, degree of recovery and sequelae. **Please note that you will lose 2 points EACH time that you list anilness, injury or surgery (up to a maximum of 10, points) and do not address these it 10 10 Childhood ilinesses (measles, mumps, rubella, chickenpox, pertussis, strep, theumatic fever, etc.) ‘Accidents/injuries (child or adult) Serious or Chronic tlinesses Hospitalizations Surgeries Health Maintenance: Immunizations (childhood and adult) — page 52 Jarvis Last examination date and results/ Screening tests PAGE TOTAL 3NSG 351 Comprehensive Health History Grading Rubric — Fall 2014 Allergies (significant adverse reactions to food, drugs, other chemicals, insects, environmental) . Include type of reaction | Medications (name, dose/route, frequency of use) prescription, OTC & home remedies, vitamins, herbs, minerals (1 point for each ~ rx, OTC, home, herbs) Family History: (p. 53 Jarvis) ‘© On submitted Genogram the following elements should be present - ‘© Gender, relationship, age, medical conditions (see pertinent negatives in book, p. 54) or cause of death included (2 points each) ‘+ Atleast 3 generations included per book (2 points) + Answer key present (2 points) + _AllPertinent negatives noted (3 points) Review of Systems: (p. 69 Bates) (Note to graders: 1/2 point off for each pertinent negative item below that is missing) * Refit [GS symptom pieUmonie when needed to elicit further information about abnormalities. * Be sure to define terms for the patient (especially items ‘GENERAL: Usual weight, recent weight change, any clothes that fit more tightly or loosely than before, weakness, fatigue, fever. 2 2 4 4 rs 5 SKIN: Rashes, lumps, sores, itching, dryness, changes in color, changes in hair or size or color of mole Head ~ Headache, head injury, dizziness, lightheadedness Eyes — Vision, glasses or contacts, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts fection, discharge. hearing Ears us, vertigo, earac 35 decre ar nonuse of hearing aids. Nose/sinuses - Frequent colds, nasal stuffiness, discharge, itching, hay fever, 35 35 nosebleeds, sinus trouble. Mouth/Throat — Condition of teeth and gums, bleeding guns, dentures, any, | 5 a5 ‘and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness. Daily dental hygiene, snoring, ‘Neck: Swollen glands, goiter, lumps, pain, stiffness of the neck. el BREASTS: Lumps, pain, discomfort, nipple discharge, self-examination practices, | 35 | 3.5 lactation. Last mammogram. ‘Axilla: tenderness, swelling i= 1 RESPIRATORY: Cough, sputum (color/ quantity), hemoptysis, dyspnea, | 6 6 wheezing, pleurisy, last chest x-ray, asthma, bronchitis, emphysema, | pneumonia, tuberculosis | * OLDCART was used to elicit further information about each abnormality above | 11 8 under review of systems. PAGE TOTAL 7m | 68sNSG 351 Comprehensive Health History Grading Rubric — Fall 2014 TARDIAC: Heart trouble, high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, irregularities of rhythm, palpitations, dyspnea, ‘orthopnea, paroxysmal nocturnal dyspnea, edema, results of Past clectrocardiograms or other cardiovascular tests, use of assistive devices (pacemaker, internal defibrillator). 6s |65 Peripheral Vascular: coldness, numbes, tingling, swelling of legs, discoloration se ands or feet, varicose veins, intermittent claudication, thrombophlebitis, ulcers. PERIPHERAL VASCULAR: Intermittent claudication (pain in the legs), lee cramps, vrricose veins, past cots in the veins, swelling in calves, legs or feet, color change in fingertips or toes during cold weather, swelling with redness, discoloration or tenderness in extremities. GASTROINTESTINAL: Trouble swallowing, heartburn, appetite, nausea/ a rng, pattern of bowel movements stool color and size, change i bowe!} habits, pain with defecation, rectal bleeding, black or tary stools, hemorshoits, canstipation diarrhea, rectal conditions (polyps, hemorshoids), abdominal pan, food intolerance, excessive belching or passing of gas, jaundice, liver or gallbladder trouble, hepatitis. 10 |9 Er NITOURINARY: Frequency of urination, polyuria, nocturia, urgency, burning tr pain during urination, hematuria, urinary infections, kidney or lank pain, kidney stones, ureteral colic, suprapubic pain, incontinence avalos. reduced force of urination, hesitancy, dribbling, pattern of voiding: REPRODUCTIVE = Female: Menstrual History age at menarche, reg\/a"1y, frequency and duration of periods, amount of bleeding, bleeding between periods or after intercourse, date of last menstrual periods, dysmenorrhea, Premenstrual symptoms. Menopause History - Age at menopause, menopause symptoms, post-menopausal bleeding. , aintrl sues . Vaginal discharge, itching, sores, lumps sexually transmitted diseases and treatments. Snstetric History - Number of pregnancies, number and type of deliveries, amber of abortions (spontaneous and induced), complications of Pregnancy, birth control methods ‘sexu! Concerns ~ sexual preference, function, satisfaction, any problems vevnaing dyspareunia. Any concerns about HIV, human papillomavirus or HV aoc it patient was born before 1971, exposure to diethystlbestrl (DES) from maternal use during pregnancy. REPRODUCTIVE - Males — Hernias, discharge from or sores on the penis, reticular pain or masses, scrotal pain or swelling, history of sexually transmitted diseases and treatment. dees concerns - Sexual habits, function, satisfaction, birth control methods, condom use, and sexual problems. Any concerns about HIV, human papillomavirus or HPV vaccine. 65 | 65 YS OLDCART or PORSTU was used when needed to elicit further information about each abnormality above under review of systems PAGE TOTALNSG 351 Comprehensive Health History Grading Rubric — Fall 2014 NEUROLOGICAL: Headache, dizziness, vertigo, fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling (or “pins and needles”), tremors or other involuntary movements, seizures, changes in mood, | 7.5 | 7.5 attention, or speech, changes in orientation, memory insight or judgment. PSYCHIATRIC: Nervousness, tension, mood, history of depression, anxiety, 35/35 memory change, and suicide attempts. ia HEMATOLOGIC: Anemia, easy bruising or bleeding, past transfusions, 2. is | transfusion reactions. | METABOLIC (ENDOCRINE) : Thyroid issues, heat or cold intolerance, excessive a [4 ‘sweating, excessive thirst or hunger, polyuria, change in glove or shoe size, Diabetes, hypoglycemia. MUSCULOSKELETAL: Muscle or joint pain, stiffness, arthritis, gout, backache, 6 6 any history of trauma, neck or low back pain, If present, describe location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness or limitation of motion or activity, * OLDCART was used when needed to elicit further information about each 3 [25 abnormality above under review of systems [UNCTIONAL ASSESSMENT 1 point for each item below (p. 57, Jarvis for questions to ask) ‘SELF ESTEEM/ SELF CONCEPT: (body-image, self-esteem, education, financial 4 4 | status) i ES ACTIVITY/ EXERCISE: daily activity profile, leisure activities, exercise pattern, a [4 recreation SLEEP/REST: Sleep pattern, rest, relaxation, sleep aids used a4 NUTRITION/ HYDRATION: 24 hour recall, Usual 24 hour intake, current appetite, 5 [Ss ‘caffeine intake, special diets ROLE/ RELATIONSHIP (Interpersonal relationships & resources): social roles, Ale support systems Spiritual Resources: Address each from Jarvis — Faith, Influence, community, a (4 address ‘COPING AND STRESS MANAGEMENT: stresses in the past year, change in ais .(2 lifestyle, methods to relieve stress [Tobacco Use crane [a Alcohol (CAGE) ‘ raat Ilicit or street drugs: marijuana, cocaine, crack, amphetamines, heroin, pain 4 [4 Killers like OxyContin/ Vicodin, barbituates (1/2 point each) | ENVIROMENTAL HAZARDS/ EXPOSURES: safety of neighborhood, access to 6 6 heat/ utilities, access to transportation, use of seatbelts, workplace hazards VIOLENCE: Has anyone hit, slapped, kicked, punched or otherwise physically 2 ala hurt you in the past year? Has anyone forced you to have any type of sexual activities within the past year? ‘Occupational Health: job, health hazards, protective equipment aa Perception of Health: page 59 — Jarvis i | PAGE TOTAL 7m [70NSG 351 Comprehensive Health History Grading Rubric - Fall 2014 ‘Summary: Analysis of the data (from interviewer's perspective) Identification of strengths Identification of risks and problems/ needs General plan of action suggested BSN nur 1g perspective maintained Formatting 5 [25 ‘© Correct formatting is used throughout PAGE TOTAL 15 [12.5 Page 1: 51.5/55 Page 2: 68.5/ 72 Page 3: 37/39 Page 4: 70/71 Pag3 5: 12.5/15 TOTAL: 239.5/252 = 95% Comments: Overall, very good job on your health history. In the first section, some information was missing like childhood immuni Ins and screening tests. Genogram looked great and all necessary components were included. OLDCART needed to be spelled out in each section were there was a positive and it was missing in several areas. For formatting, you were not to use full sentences except in the summary. Good summary!