NURS 680 A
Complete Subjective Medical History Assignment
You will select a “patient” (friend or family member) on whom you will perform a complete history. For this assignment, the patient should be a healthy adult male or female age (18–65) with a single chief complaint
NOTE: DO NOT USE REAL NAMES OR INITIALS OR OTHERWISE IDENTIFY YOUR “PATIENT.” FAILURE TO MAINTAIN PRIVACY WILL RESULT IN A FAILING SCORE.
• The Subjective History documentation must follow the format below (see page 2).
• HPI must be presented in a paragraph, with the rest of the data, including ROS, must be presented in a “list” format.
• The health history must contain all required elements as outlined in the rubric.
• No physical exam is required for this assignment; it is to cover subjective information only.
• The assignment submission should be a single document that contains:
1. The Complete Subjective Medical History (see format on page 2)
2. A discussion of National Guidelines and ARHQ Health Promotion recommendations (according to the United States Preventative Task Force [USPTF]) appropriate to the patient interviewed.
Complete Subjective Medical History Assignment
*Follow this format
Subjective Data
• Biographic Data – Age/race/gender, occupation, language, and communication needs.
• Source – and reliability
• Chief Complaint (reason for seeking care) – make every attempt to use patient’s own words.
• History of Present Illness (HPI) – complete, clear, chronological account of events prompting patient to seek care. Use OLDCARTS or PQRST to gather data but do not include acronym in HPI. Document in paragraph format.
• Past Medical History (PMH) – childhood, adult illnesses, serious illnesses/hospitalizations, obstetric hx, immunizations, and last exam.
• Allergies, medication, food, environmental
• Medications – Rx, OTC, herbal, etc.
• Family History – Going back three generations note the following: age, health status and if applicable cause of death of each family member
• Personal and Social History – interests, support systems, occupation, highest level of education, job history, financial situation, spiritual beliefs, lifestyle (include: Tobacco, Illicit drug & ETOH use), alternative health care practices, sexual and obstetric history.
• Review of Systems (ROS) – series of questions from head to toe. Use these as headers to organize your documentation. Must be in the following order – include health promotion practices:
• General Survey
• Integumentary
• Head, Eyes, Ears, Nose, and Throat
• Neck/thyroid
• Breasts and axillary lymph nodes
• Respiratory
• Cardiovascular
• Peripheral vascular
• Gastrointestinal
• Genitourinary
• Genital/Reproductive system
• Sexual health
• Musculoskeletal
• Neurological (must include reflexes on PE)
• Hematologic
• Endocrine
• Functional assessment – include activities of daily living
• Self-esteem/self-concept
• Activity/exercise
• Sleep/rest/nutrition, include
• Nutritional status assessment- identify if patient is at risk for malnutrition or over-nutrition
• Interpersonal relationships
• Spiritual resources
• Coping and stress management
• Personal habits – alcohol, tobacco, street drugs
• Environment/Hazards
• Intimate partner violence
• Occupational health
• Perception of health
• Developmental Competence – children, pregnant women, older adult.
