Wednesday, May 15, 2013

Health Assessment Health History Interview Assignment

I remember when I filled out my Health History Interview Assignment, I felt like I had no idea what I was doing. In retrospect there are several things I wish I would have done differently. For example, when you’re filling out your health history assignment, make sure to leave no blank spaces. If something doesn't apply to the patient (pt.) you’re interviewing, write, “N/A”. For example, if you’re interviewing a male pt. in the obstetric section, write N/A in the blank next to gravida. Since he’s a male, it doesn't apply to him. If you don’t know what gravida and parity mean, look them up in a medical dictionary. It's important to know the difference.

When you’re constructing your genogram, make sure to include a key for your shapes and colors. I forgot to do this when I created my genogram. You can find a sample genogram in your Physical Assessment work book in the answer key for worksheet 26.

In the review of systems section (ROS), you can write “not indicated” when a pt. responds that they have not experienced a particular condition. For example, “headaches, head injuries, and dizziness not indicated.” Or you could write, "No history of headaches, head injuries, and dizziness." If on the other hand your pt. experiences headaches and dizziness due to a head injury, explain the reason for his/her head trauma and the location of the pain and any other important details. For example: “Pt. reports headaches on the left side of the head and dizziness due to a head injury experienced during a car crash seven days ago.”

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