MODULE 1

in
HEALTH
ASSESSMENT
(Health History)

AUTHORS:

Second Semester, SY
2024-2025
 TABLE OF

Introduction 3

Learning Outcomes 3

Module Organizer 3

Directions 5

Lesson 1 Overview 6

Lesson 2 The Nursing Process 9

Lesson 3 Assessment 22

Lesson 4 The Interview and Health History 25

Lesson 5 The Comprehensive Adult Health History 31

Lesson 6 Collecting the Objective Data 35

Critical Thinking Activity 42

References 44

Appendix A 45
 HEALTH ASSESSMENT

INTRODUCTIO
AssessingN
a client’s health status is a major component of nursing
care and has two aspects: (1) the nursing health history and (2) the
physical examination. A physical examination can be any of three
types: (1) a
complete assessment, (2) an examination of a body, or (3) an
examination of a body area
This module provides a road map to clinical proficiency. This will
help you get started on how to gather data or information to help
identify possible or actual nursing or medical problems.

LEAR
NING
After studying the module, you should be able to:

1. Identify the purposes of the physical examination.

2. Explain the four techniques used in the physical examination:
inspection, palpation, percussion, and auscultation.
3. Identify expected findings during the health assessment.
4. Describe suggested sequencing to conduct a physical health
examination in an orderly fashion.
5. Discuss variations in examination techniques appropriate for
clients of different ages.
6. Recognize when it is appropriate to delegate assessment
skills to unlicensed assistive personnel.
7. Demonstrate appropriate documentation and reporting of
health assessment.

MODULE
ORGANIZERS
Hello dear students! I am Jewell F. Llavore , your Instructors for
this course. In case that you will encounter difficulties, feel free to
discuss it with us during the scheduled online meetings. Or you
may opt to contact us to thru the following contact details:

NAME OF
FACULTY
MEMBE
Jewell Llavore jllavore@dmmmsu.edu.ph

Dress Code
During VIRTUAL RLE meetings, consultations and return
demonstrations, you are expected to wear the prescribed related
learning experience. Failure to wear the prescribed uniform shall be
considered as unexcused absence from duty. In case you left your
uniform in your respective boarding house last semester, you are
required to wear a white polo/ collared shirt. The following are the
description of your prescribed uniform during RLE and CP:

In the clinical setting

 For Females: A white dress that is knee level or one inch
below the knee.
 For Males: White pants and a white polo shirt with a plain
white undershirt with a pin othe n left collar

In the community setting (for both men and women)

 Type A (RHU Uniform): White blouse and a polo shirt
with RHU (dark blue) pants
 Type B: Dark maong pants with CCHAMS T-shirt
 Type C: Any attire appropriate to the activity as prescribed
by your Clinical Instructor

Grooming Standard
 For female students who will attend the VIRTUAL RLE
meetings, consultation and return demonstrations, you are
required to observe the following:
Hair should not touch the collar. Bangs should not
extend below the eyebrow. Long hair should be braided
or secured neatly into a bun.
Black or dark brown hair clips may be used but no
fancy clips, ribbons, and headbands shall be allowed
Headbands should be flat and black with no more
than 1-inch width
Only light make-up is allowed
No colored contact lens is allowed
No polished or colored fingernails is allowed
Hair color should be dark brown and black ONLY.

 For male students who will attend the VIRTUAL RLE

meetings, consultation and return demonstrations, you are
required to observe the following:
Haircut should either be high cut, semi-high cut, flat
top, crew cut, or semi low cut. Hair at the back should
be barber’s cut.
No spikes, fancy or other very fashionable hairstyle.
No dyeing of hair is allowed.
No moustache, beard or sideburns is allowed
No make up
No colored contact lens is allowed
Hair color should be dark brown and black ONLY.

 Accessories
Only the prescribed watch shall be allowed. No
accessories or jewelry shall be worn during VIRTUAL
RLE meetings, consultation and return demonstrations.
Married individuals are allowed to wear their wedding
rings

Requirements/ Evaluation
At the end of every clinical module, you are being
evaluated by your clinical instructor assigned to you
which will be submitted to your respective clinical level
coordinator. Requirements are assigned in each module
 and deadline of submission is 1 week after the end of
each module. Format and templates for Requirements
are still the same. Rubrics will be attached in each
module. Late submission of requirements will be
entertained depending on the reason behind it. You are
required to submit a letter of explanation to your clinical
instructor assigned to you and he/she will classify it if
excused or unexcused. The equivalent grade of
requirements that are submitted late will be 75%.
Meanwhile, those who will not pass their requirements
will automatically have a grade of ZERO. You are still
required to have your clinical duty in the area but in
case that the current situation will still the same, your
final grade will be marked as IN PROGRESS. Catch up
plan will be created to meet your clinical duty needs.

DIRECTI
DIRECTION
There are S
four lessons in the module. Read each lesson
carefully. Lesson 1 to 2 starts with the brief overview of the topic and
followed by steps in the nursing process. After reading each lesson, you are
required to answer the exercises/activities to find out how much you have
benefited from it. Work on these exercises carefully because they are
graded and submit your output to my email given to you. Rubrics will be
used to evaluate your outputs that are seen in the appendix section of this
module.

Good luck and happy reading!

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Lesson 1
OVERVIEW
I. Introduction to Health Assessment

Health Assessment:
 Is holistic data collection and analysis
 Utilizes the nursing process
 Incorporates critical thinking.

II. COMPONENTS of Health assessment

a. Health History
b. Physical Examination

III. TERMINOLOGY

 Diagnosis – It is the determination of the nature and extent of a disease.

 Prognosis – It is the forecast of the course and duration of the disease.
 Etiology – It is the science of the cause of a disease.
 Signs – The presence of a disease that can be seen or elicited e.g. Fever.
 Symptoms – Any evidence as to the nature and location of a diseases noted by
the client.
 Subjective Symptoms
– When the symptoms are noted by the client himself. e.g. Pain.
 Objective Symptoms
– When the symptoms are noted by the observer as well as by the client.
e.g. Jaundice.
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IV. Accepted Nursing and Medical Abbreviations

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V. Nurse’s Role in Health Assessment

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Lesson 2
THE NURSING PROCESS
I. THE NURSING PROCESS
 a systematic, rational method of planning and providing nursing care.
 Its purpose is to identify a client’s healthcare status, and actual or
potential health problems, to establish plans to meet the identified needs,
and to deliver specific nursing interventions to address those needs.
 cyclical; that is, its components follow a logical sequence, but more than
one component may be involved at one time. At the end of the first cycle,
care may be terminated if goals are achieved, or the cycle may continue
with reassessment, or the plan of care may be modified

II. 4 PHASES OF THE NURSING PROCESS

ASSESSING
• Collect data
• Organize data
• Validate data
• Document data

DIAGNOSING
• Analyze data
• Identify health problems,
risks, and strengths
• Formulate diagnostic
Statements

PLANNING
• Prioritize problems/diagnoses
• Formulate goals/desired outcomes
• Select nursing interventions
• Write nursing interventions

IMPLEMENTING
• Reassess the client
• Determine the nurse’s need for assistance
• Implement the nursing interventions
• Supervise delegated care
• Document nursing activities

EVALUATING
• Collect data related to outcomes
• Compare data with outcomes
• Relate nursing actions to client goals/outcomes
• Draw conclusions about the problem status
• Continue, modify, or terminate the client’s care plan
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III. DISCUSSION
A. ASSESSMENT
 the systematic and continuous collection, organization, validation,
and documentation of data (information)
 Nursing assessments focus on a client’s responses to a health
problem.
 A nursing assessment should include the client’s perceived needs,
health problems, related experiences, health practices, values, and
lifestyles. To be most useful, the data collected should be relevant
to a particular health problem.

COLLECTING DATA

A database contains all the information about a client; it includes

the nursing health history (Box 11–1), physical assessment,
primary care provider’s history and physical examination, results
of
laboratory and diagnostic tests, and materially contributed by
other
health personnel.

1. Types of Data

1.a. Subjective data

 also referred to as symptoms or covert data
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 apparent only to the person affected and can be described
or verified only by that person.
 include the client’s sensations, feelings, values, beliefs,
attitudes, and perception of personal health status and life
situation.

Ex.
 Itching
 pain
 feelings of worry

1.b. Objective data

 also referred to as signs or overt data
 detectable by an observer or can be measured or tested
against an accepted standard.
 They can be seen, heard, felt, or smelled, and they are
obtained by observation or physical examination.
 During the physical examination, the nurse obtains
objective data to validate subjective data and to
complete the assessment phase of the nursing process.

Ex.
 a discoloration of the skin
 a blood pressure reading

2. Sources of Data
2.a. Primary Data or Sources
 The client is a source of data

2.b. Secondary Data or Sources

 Family members or other support persons, other health
professionals, records and reports,
 laboratory and diagnostic analyses, and relevant
literature are secondary or indirect sources.
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3. Data Collection Methods

3.a. OBSERVING
 To observe is to gather data by using the senses. Observing
is a conscious, deliberate skill that is developed through
effort and with an organized approach.
 Although nurses observe mainly through sight, most of the
senses are engaged during careful observations.
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3. b. Interviewing
 An interview is a planned communication or a conversation
with a purpose (SEE LESSON 4)

3.c. Examining (SEE LESSON 6)

 The physical examination or physical assessment is a
systematic data collection method that uses observation
(i.e., the senses of sight, hearing, smell, and touch) to
detect health problems.
 To conduct the examination, the nurse uses techniques of
inspection, auscultation, palpation, and percussion

4. ORGANIZING DATA
 The nurse uses a written (or electronic) format that
organizes the assessment data systematically. This is
often referred to as a nursing health history, nursing
assessment, or nursing database form.

5. DOCUMENTING DATA (Further discussion will be given in

Module 2)
 To complete the assessment phase, the nurse records
client data.
 Accurate documentation is essential and should include
all data collected about the client’s health status.
 Data are recorded in a factual manner and not
interpreted by the nurse.

6. VALIDATING ASSESSMENT DATA

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B. DIAGNOSING
 the second phase of the nursing process.
 In this phase, nurses use critical thinking skills to interpret
assessment data and identify client strengths and problems

1. NANDA NURSING DIAGNOSES

 To use the concept of nursing diagnoses effectively in
generating and completing a nursing care plan, the nurse
must be familiar with the definitions of terms used and the
components of nursing diagnoses.

2. STATUS OF THE NURSING DIAGNOSES

 “Status of the nursing diagnosis refers to the actuality or
potentiality of the problem/syndrome or the categorization of the
diagnosis as a health promotion diagnosis” (Herdman &
Kamitsuru, 2014, p. 100).

2.a. An actual diagnosis

- a client problem that is present at the time of the nursing
assessment.
- An actual nursing diagnosis is based on the presence of
associated signs and symptoms.

Examples:
 Ineffective Breathing Pattern
 Anxiety

2.b. A health promotion diagnosis

- relates to clients’ preparedness to implement behaviors to
improve their health condition.
- These diagnosis labels begin with the phrase Readiness for
Enhanced, as in Readiness for Enhanced Nutrition.

2.c. A risk nursing diagnosis

- a clinical judgment that a problem does not exist, but the
presence of risk factors indicates that a problem is likely to
develop unless nurses intervene.
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- For example, all people admitted to a hospital have some
possibility of acquiring an infection; however, a client with
diabetes or a compromised immune system is at higher risk
than others.

Example:
 Risk for Infection
2.d. A syndrome diagnosis
- assigned by a nurse’s clinical judgment to describe a cluster of
nursing diagnoses that have similar interventions (Herdman &
Kamitsuru, 2014, p. 23).

3. COMPONENTS OF A NANDA NURSING DIAGNOSIS

 A nursing diagnosis has three components: (1) the problem
and its definition, (2) the etiology, and (3) the defining
characteristics. Each component serves a specific purpose.
3.a. PROBLEM (DIAGNOSTIC LABEL) AND DEFINITION
- The problem statement, or diagnostic label, describes the
client’s health problem or response for which nursing
therapy is given.
- The purpose of the diagnostic label is to direct the
formation of client goals and desired outcomes.
- It may also suggest some nursing interventions.

 Qualifiers are words that have been added to some

NANDA
labels to give additional meaning to the diagnostic
statement, for
example:
• Deficient : (inadequate in amount, quality, or
degree; not sufficient; incomplete)

• Impaired: (made worse, weakened, damaged,

reduced, deteriorated)

• Decreased (lesser in size, amount, or degree)

• Ineffective (not producing the desired effect)

• Compromised (to make vulnerable to threat).

3.b. ETIOLOGY (RELATED FACTORS AND RISK FACTORS)

- The etiology component of a nursing diagnosis
identifies one or more probable causes of the health
problem, gives direction to the required nursing
therapy, and enables the nurse to individualize the
client’s care
- Table 12–2 provides examples of problems that have
different etiologies and therefore require different
interventions.
- Each diagnostic label approved by NANDA carries a
definition that clarifies its meaning. For example, the
definition of the diagnostic label Activity Intolerance is
shown in Table 12–1.
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4. DEFINING CHARACTERISTICS
- the cluster of signs and symptoms that indicate the presence of
a particular diagnostic label.
- For actual nursing diagnoses, the defining characteristics are
the client’s signs and symptoms.
- For risk nursing diagnoses, no subjective and objective signs
are present. Thus, the factors that cause the client to be more
vulnerable to the problem form the etiology of a risk nursing
diagnosis.

5. DIFFERENTIATING NURSING DIAGNOSES FROM MEDICAL DIAGNOSES

- A nursing diagnosis is a statement of nursing judgment and
refers to a condition that nurses, by virtue of their education,
experience, and expertise, are licensed to treat.

- A medical diagnosis is made by a physician and refers to a

condition that only a physician can treat. Medical diagnoses
refer to disease processes—specific pathophysiologic responses
that are fairly uniform from one client to another. In contrast,
nursing diagnoses describe the human response, a client’s
physical, sociocultural,
psychological, and spiritual responses to an illness or a health
problem.

- A client’s medical diagnosis remains the same for as long as

the
disease process is present, but nursing diagnoses change as
the client’s responses change.
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6. FORMULATING DIAGNOSTIC STATEMENTS

- Most nursing diagnoses are written as two-part or three-part
statements, but there are variations of these.
- The two parts are joined by the words related to rather than
due to.
- The phrase due to implies that one part causes or is responsible
for the other part. By contrast, the phrase related to merely
implies a relationship.

6.a. BASIC TWO-PART STATEMENTS

- The basic two-part statement includes the following:

i. Problem (P): statement of the client’s response (NANDA

label)
ii. Etiology (E): factors contributing to or probable causes
of the responses

6.b. BASIC THREE-PART STATEMENTS

- The basic three-part nursing diagnosis statement is called the
PES format and includes the following:

i. Problem (P): statement of the client’s response

(NANDA label)
ii. Etiology (E): factors contributing to or probable
causes of the response
iii. Signs and symptoms (S): defining characteristics
manifested by the client.
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c. PLANNING
- a deliberative, systematic phase of the nursing process that
involves decision making and problem solving.
- The nurse refers to the client’s assessment data and diagnostic
statements for direction in formulating client goals and
designing the nursing interventions required to prevent,
reduce, or eliminate the client’s health problems

 A nursing intervention is “any treatment, based upon

clinical judgment and knowledge, that a nurse performs
to enhance patient/client outcomes” (Bulechek, Butcher,
Dochterman, & Wagner, 2013,

c.1. TYPES OF PLANNING

i. Initial Planning
- The nurse who performs the admission assessment
usually develops the initial comprehensive plan of
care. This nurse has the benefit of seeing the client’s
body language and can also gather some intuitive
kinds of information that are not available solely from
the written database.
- Planning should be initiated as soon as possible after
the initial assessment.
ii. Ongoing Planning
- All nurses who work with the client do ongoing planning.
- As nurses obtain new information and evaluate the
client’s responses to care, they can individualize the
initial care plan further.
- occurs at the beginning of a shift as the nurse plans the
care to be given that day. Using ongoing assessment
data, the nurse carries out daily planning for the
following purposes:
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1. To determine whether the client’s health status
has changed
2. To set priorities for the client’s care during the shift
3. To decide which problems to focus on during the
shift
4. To coordinate the nurse’s activities so that more
than one problem can be addressed at each client
contact.

iii. Discharge Planning

- the process of anticipating and planning forbneeds
after discharge, is a crucial part of a comprehensive
health care plan and should be addressed in each
client’s care plan

 STANDING ORDER is a written document about policies, rules,

regulations, or orders regarding client care.

c.2. FORMATS FOR NURSING CARE PLANS

- Although formats differ from agency to agency, the care plan is
often organized into four sections: (1) problem/nursing
diagnoses, (2) goals/desired outcomes, (3) nursing
interventions, and (4) evaluation.

c.3. GUIDELINES FOR WRITING NURSING CARE PLANS

i. Date and sign the plan. The date the plan is written is essential
for evaluation, review, and future planning. The nurse’s signature
demonstrates accountability to the client and to the nursing
profession, since the effectiveness of nursing actions can be
evaluated.

ii. Use category headings. “Nursing Diagnoses,” “Goals/Desired

Outcomes,” “Nursing Interventions,” and “Evaluation” are the
common headings. Include a date for the evaluation of each goal.

iii. Use standardized/approved medical or English symbols and

key words rather than complete sentences to communicate your
ideas unless agency policy dictates otherwise. For example, write
“Turn and reposition q2h” rather than “Turn and reposition the
client every two hours.” Or, write “Clean wound −c H2O2 bid”
rather than “Clean the client’s wound with hydrogen peroxide
twice a day, morning and evening.” See Lesson 1 for the
list of standard medical abbreviations.

iv. Be specific. Because nurses are now working shifts of different

lengths, with some working 12-hour shifts and some working
8-hour shifts, it is even more important to be specific about
expected timing of an intervention. If the intervention reads
“change incisional dressing q shift,” it could mean either twice in
24 hours, or three times in 24 hours, depending on the shift time.
This miscommunication becomes even more serious when
medications are ordered to be given “q shift.” Writing down specific
times during the 24-hour period will help clarify.

v. Refer to procedure books or other sources of information rather

than including all the steps on a written plan. For example,
write “See unit procedure book for tracheostomy care,” or attach
a standard nursing plan about such procedures as radiation-
implantation
care and preoperative or postoperative care.

vi. Tailor the plan to the unique characteristics of the client by

ensuring that the client’s choices, such as preferences about the
times of care and the methods used, are included. This reinforces
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the client’s individuality and sense of control. For example, the
written nursing intervention “Provide prune juice at breakfast
rather than other juice” should indicate that the client was given
a choice of beverages.

vii. Ensure that the nursing plan incorporates preventive and health
maintenance aspects as well as restorative ones. For example,
carrying out the intervention “Provide active-assistance ROM
(range-of-motion) exercises to affected limbs q2h” addresses the
goal of preventing joint contractures and maintaining muscle
strength and joint mobility.

viii. Ensure that the plan contains ongoing assessment of the client
(e.g., “Inspect incision q8h”).

viii. Include collaborative and coordination activities in the plan . For

example, the nurse may write interventions to ask a nutritionist
or physical therapist about specific aspects of the client’s care.

ix. Include plans for the client’s discharge and home care needs . The
nurse begins discharge planning as soon as the client has been
admitted. It is often necessary to consult and make arrangements
with the community health nurse, social worker, and specific
agencies
that supply client information and needed equipment.

c.4. ESTABLISHING CLIENT GOALS/ DESIRED OUTCOMES

i. Short-Term Goal
ii. Long-Term Goal
 GUIDELINES FOR WRITING GOALS/DESIRED OUTCOMES
The following guidelines can help nurses write useful goals and desired
outcomes:
1. Write goals and outcomes in terms of client responses, not
nursing
activities. Beginning each goal statement with The client will may
help focus the goal on client behaviors and responses. Avoid
statements that start with enable, facilitate, allow, let, permit, or
similar verbs followed by the word client. These verbs indicate
what the nurse hopes to accomplish, not what the client will do.

Correct: The client will drink 100 mL of water per hour (client
behavior).
Incorrect: Maintain client hydration (nursing action).

2. Be sure that desired outcomes are realistic for the client’s

capabilities, limitations, and designated time span, if it is
indicated. Limitations refers to finances, equipment, family
support, social services, physical and mental condition, and time.
For example, the outcome “Measures insulin accurately” may be
unrealistic for a client who has poor vision due to cataracts.

3. Ensure that the goals and desired outcomes are compatible

with the therapies of other professionals. For example, the
outcome “The client will increase the time spent out of bed by 15
minutes each day” is not compatible with a primary care provider’s
prescribed therapy of bed rest.

4. Make sure that each goal is derived from only one nursing
diagnosis.
For example, the goal “The client will increase the amount
of nutrients ingested and show progress in the ability to feed self ”
is derived from two nursing diagnoses: Imbalanced Nutrition:
Less Than Body Requirements and Feeding Self-Care Deficit.
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Keeping the goal statement related to only one diagnosis
facilitates
evaluation of care by ensuring that planned nursing interventions
are clearly related to the diagnosis.

5. Use observable, measurable terms for outcomes. Avoid words

that are vague and require interpretation or judgment by the
observer. For example, phrases such as increase daily exercise
and improve knowledge of nutrition can mean different things
to different people. If used in outcomes, these phrases can lead
to disagreements about whether the outcome was met. These
phrases may be suitable for a broad client goal but are not
sufficiently
clear and specific to guide the nurse when evaluating
client responses.

6. Make sure the client considers the goals/desired outcomes

important
and values them. Some outcomes, such as those for
problems related to self-esteem, parenting, and communication,
involve choices that are best made by the client or in collaboration
with the client.

c.5. TYPES OF NURSING INTERVENTIONS

 Independent interventions
- those activities that nurses are licensed to initiate on
the basis of their knowledge and skills.
- They include physical care, ongoing assessment,
emotional support and comfort, teaching, counseling,
environmental management, and making referrals to
other health care professionals.

 Dependent interventions
- are activities carried out under the orders or supervision of a
licensed physician or other health care provider authorized to
write orders to nurses.

 Collaborative interventions
- are actions the nurse carries out in collaboration with other
health team members, such as physical therapists, social
workers, dietitians, and primary care providers.
- Collaborative nursing activities reflect the overlapping
responsibilities of, and collegial relationships among, health
personnel

d. IMPLEMENTING
 In the nursing process, implementing is the action phase in
which the nurse performs the nursing interventions.

e. EVALUATING
 To evaluate is to judge or to appraise. Evaluating is the fifth
phase of the nursing process. In this context, evaluating is a
planned, ongoing, purposeful activity in which clients and
health care professionals determine (a) the client’s progress
toward achievement of goals/ outcomes and (b) the
effectiveness of the nursing care plan.
 Evaluation is an important aspect of the nursing process
because conclusions drawn from the evaluation determine
whether the nursing interventions should be terminated,
continued, or changed

e.1. COMPARING DATA WITH DESIRED OUTCOMES

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- If the first two parts of the evaluating process have been
carried out effectively, it is relatively simple to determine
whether a desired outcome has been met. Both the
nurse and client play an active role in comparing the
client’s actual responses with the desired outcomes.
- When determining whether a goal has been achieved,
the nurse can draw one of three possible conclusions:

1. The goal was met; that is, the client response is the
same as the desired outcome.
2. The goal was partially met; that is, either a short-term
outcome was achieved but the long-term goal was not,
or the desired goal was incompletely attained.
3. The goal was not met.

Lesson 3
ASSESSMENT

I. Assessment
- Is systematic and continuous:
 collection
 organization
 validation
 documentation of data.

PURPOSE:
Assessment is part of each activity the nurse does for and with the patient.
1. To validate a diagnosis (Basis for accurate diagnosis)
2. To provide the basis for effective nursing care (To evaluate nursing care)
3. To promote holistic nursing care
- To provide effective and innovative nursing care
4. To help in effective decision making
5. To collect data for nursing research
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II. Health Assessment
 Requires proficient communication skills and interviewing techniques.
 Requires the establishment of rapport and trust.
 Considers cultural aspects.

A. Phases of taking a health history

1. The Interview phase.
2. The recording phase.

B. Guidelines for Taking Nursing History

1. Private, comfortable, and quiet environment.
2. Allow the client to state problems and expectations for the interview.
3. orient the client the structure, purposes, and expectations of the history.
4. Communicate and negotiate priorities with the client
5. Listen more than talk.
6. Observe non-verbal communications
e.g. "body language, voice tone, and appearance".
7. Review information about past health history before starting interview.
8. Balance between allowing a client to talk in an unstructured manner and the
need to structure requested information.
9. Clarify the client's definitions (terms & descriptors)
10. Avoid yes or no questions (when detailed information is desired).

 Open-ended questions- when detailed information is desired;

allows patient to talk freely.
 Closed- ended questions- answerable by yes or no,
 when specific information is desired.
11. Write adequate notes for recording
12. Record nursing health history soon after interview.

C. Types of Nursing Health History

1. Complete health history:

taken on initial visits to health care facilities.
2. Interval health history:
collect information in visits following the initial database
3. Problem- focused health history:
collect data about a specific problem

III. General Survey

 Study of the whole individual

 Overall impression
 Begins with the first encounter with a person
 Introduction to the physical assessment
 Composed of 4 parts: physical appearance, body structure, mobility & behavior
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A. Physical Appearance
 Age
 Sex
 LOC (level of consciousness)
 Skin color
 Facial features

B. Body Structure
 Stature
 Nutrition
 Symmetry
 Posture
 Position
 Body contour

C. Mobility
 Gait
 Range of Motion (PROM or AROM)

D. Behavior
 Facial expression
 Mood
 Speech
 Dress/Hygiene

E. Height and weight

F. Vital Signs

G. Transcultural Considerations
H. Note Signs and Symptoms of distress/pain (Further Discussion of Pain
in RLE Module on Vital Signs)

Assessing Distress/Pain

 Assessment includes:

S- Severity

L- Location

I- Influencing factors

D- Duration

A- Associated Symptoms

 Pain assessment = 5th vital sign

 Utilize the pain scale
 Understand chronic vs acute pain
 Recognize gender, transcultural and developmental factors effecting pain
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Lesson 4
THE INTERVIEW AND
HEALTH HISTORY

I. Interviewing
 Obtaining a valid nursing health history requires professional, interpersonal,
and interviewing skills. The nursing interview is a communication process that
has two
focuses:

1. Establishing rapport and a trusting relationship with the client to elicit

accurate and meaningful information.

2. Gathering information on the client’s developmental, psychological,

physiologic, sociocultural, and spiritual statuses to identify deviations that
can be treated with nursing and collaborative interventions or strengths that
can be enhanced through nurse–client collaboration.

II. Nurse–patient Relationship - based on the therapeutic use of self through

verbal and nonverbal communication skills

 Therapeutic communication - a basic nursing tool in which the nurse

ensures that the interaction focuses on the patient and the patient’s
concerns

KEY ELEMENTS:
 26
a. Caring - the ability to connect with the patient and demonstrate
compassion, sensitivity, and patient-centered care.
b. Empathy - ability to perceive, reason, and communicate understanding of
another person’s feelings without criticism
- It is being able to see and feel the situation from the patient’s
perspective, not the nurse’s
A. Nonverbal Communication Skills

 The nurse’s physical appearance, facial expression, posture and positioning in

relation to the patient, gestures, eye contact, voice, and use of touch are all
important components

B. Verbal Communication Skills

B.1. Effective interviewing skills:

1. Active listening - the ability to focus on patients and their perspectives. It
requires the nurse to constantly decode messages, including thoughts,
words, opinions, and emotions.
2. Restatement - relates to the content of the communication.
- The nurse makes a simple statement, usually using the same words as
the patients.
- The purpose is to ask patients to elaborate.
3. Reflection - is like restatement; however, instead of simply echoing the
patient’s comments, the nurse summarizes the main themes.
4. Encourage elaboration (facilitation) - assists patients to describe
problems more completely. Responses encourage patients to say more,
continue the conversation, and show patients that the nurse is interested.
5. Purposeful silence - allows patients time to gather their thoughts and
provide accurate answers
6. Focusing - helps when patients stray from topic and need redirection.
7. Clarification- is important when the patient’s word choice or ideas are
unclear.
8. Summarizing - happens at the end of the interview
- helps to reassure the patient that he or she has been heard accurately.

B.2. - Nontherapeutic Responses

1. False reassurance - helps to minimize uncomfortable feelings but may
mislead a patient into minimizing a health concern or neglecting to perform a
needed health-promoting activity.
2. Sympathy - is feeling what a patient feels from the viewpoint of the nurse, not
of the patient.
3. Unwanted advice - although common in social situations, is nontherapeutic,
because it usually is from the nurse’s perspective, not the patient’s
4. Biased (leading) questions - impose judgment and lead patients to respond
in the way they think the nurse wants
5. Changing the subject - may happen when a situation is uncomfortable for a
nurse because of personal experiences or coping mechanisms
6. Environmental distractions
7. Too many technical terms or too much information - can overwhelm
patients
8. Talking too much and interrupting - the professional nurse listens more
than talks

III. Phases of the Interview Process

A. Preinteraction Phase
- before meeting with the patient, the nurse collects data from the
medical record and reviews the patient’s history of medical illnesses or
surgeries, current medication list, and problem list

B. Beginning Phase
 27
- the nurse initially introduces herself or himself by name, states the
purpose of the interview, and asks the patient his or her preferred name.
- the beginning phase may continue with the discussion of neutral topics
(eg, the weather) if the patient seems anxious
-ensuring privacy within the specific health care setting by pulling
drapes, closing doors, or moving to a remote area before proceeding is
essential, especially considering confidentiality guidelines.

C. Working Phase
- the nurse asks specific questions; TWO TYPES:
a. Closed-ended.
- (direct) questions yield “yes” or “no” answers. An example is “Do
you have a family history of heart disease?” They are important in
emergencies or when a nurse needs to establish basic facts.

b. Open-ended questions
-require patients to elaborate
-broad and provide responses in the patient’s own words
- the key to understanding symptoms, health practices, and
areas requiring intervention

D. Closing Phase
- The nurse ends the interview by summarizing and stating what the two to
three most important patterns or problems might be, as well as asking
patients if they would like to mention or need anything else

IV. Intercultural Communication - the sender of an intended message

belongs to one culture, while the receiver is from another.
- The nurse must individualize care to the specific patient’s practices and
always use principles of communication etiquette (good manners that
show respect for others) when working with those from various cultures,
ethnicities, and religions.

V. Gender and Sexual Orientation Issues

- Communication styles vary between and within each gender group. Men
may prefer more information and facts, whereas women might
appreciate more social and emotional interactions.

VI. Special Situations

1. Hearing Impairment
 28
- For patients using hearing aids, the nurse makes sure that such devices
are turned on and working. Gentle touch and visual signals can verify
that patients are paying attention. Closing the door limits background
noise. The nurse gives thorough explanations, provides diagrams and
pictures, supplies written information, and asks open-ended questions.
2. Low Level of Consciousness
- Patients with a low level of consciousness may be unable to provide
interview answers. In this case, the nurse needs to rely on family
members and previous documentation.
3. Cognitive Impairment
- Patients with dementia often have word-finding difficulties. They may
substitute sound-alike words and sounds, making conversation difficult to
track. Allowing these patients time to process as much as possible to
avoid a one-sided conversation is essential.
4. Mental Health Issues
- Patients with mental health issues may have difficulty attending to and
sequencing communication. The nurse should observe patients for
behaviors that indicate distraction, such as looking around the room or
appearing to hear noises.
a. Anxiety - an expected response to a threat to well-being
- nail-biting, foot tapping, sweating, and pacing
- use active listening, honesty, and a calm and unhurried manner to
reduce anxiety
- teaches breathing and relaxation exercises and provides structure so
that patients know they will remain safe
b. Crying - use therapeutic communication techniques rather than
progressing with additional interview questions
c. Anger - the nurse listens for associated themes and avoids becoming
defensive or personalizing the
d. Alcohol or Drug Use - Patients with chemical impairment have
difficulty answering complex questions, so the nurse uses direct and
simple questions instead.
- Interview questions include the type of drug, amount ingested, and date
and time of the last drink or use
 29

VII. Health History

- forms the foundation for care as patterns emerge and problems are identified.
-It provides context for the current situation and a more complete picture of
how issues are related
- establishes trust with patients

A. SOURCES

1. PRIMARY DATA SOURCE – patient

2. SECONDARY DTA – charts and family members

VIII. Lifespan Considerations

A. Pregnant Women

A comprehensive health history is performed at the first prenatal visit. The

nurse obtains details about the current pregnancy, any previous pregnancies,
obstetrical/gynecological history, the family, and psychosocial profile. He or she
also collects history on nutrition, genetically inherited diseases, social networks,
occupation, and violence. Patients may be accompanied by family members or
their partners. The nurse builds a relationship with support people as part of the
process if patients give permission.

B. Newborn, Children, and Adolescent

Health history for infants and children is provided by parents or other adult
caregivers. As children move into adolescence, the nurse may interview both
the parent and the teen. The relationship between the adolescent and the
 30
parent determines how the nurse collects data. It may be more comfortable and
reliable to ask questions directly of the teen regarding sexual activity and
recreational drug use with the parent stepping out of the room for a moment.

C. Older Adult

Increased risk for sensory deficits (eg, vision or hearing loss) might alter history
taking with older adults. These patients may have more complex histories
because of their increased prevalence of disease. It is important to identify the
pattern of the illnesses and recognize how they might be related. In addition to
the increased risk of illness because of family history, lifestyle choices also
begin to influence health later in life.

D. Cultural and Environmental Considerations

As previously discussed, the nurse considers religious and spiritual, social,

political, economic, and educational factors that influence beliefs and care
decisions. The nurse is also aware of illnesses that are more common among
groups of patients, such as diabetes or genetically inherited diseases. Questions
regarding the patient’s environment might include safety in the home,
transportation issues, or community involvement. An exposure history includes
the agent, length of exposure, and type of exposure. The nurse can use this
information to make a referral for further evaluation and follow-up if necessary.
 31

Lesson 5
THE COMPREHENSIVE
ADULT HEALTH
HISTORY
I. Biographical Data

This includes:
 Full name
 Address and telephone numbers
 Birth date and birthplace.
 Sex
 Religion and race.
 Marital status.
 Social security number.
 Occupation (usual and present)
 Source of referral
 Usual source of healthcare.
 Source and reliability of information.
 Date of interview.

II. Reliability
 Varies according to the patient’s memory, trust, and mood.

III. Chief Complaint: “Reason for Hospitalization”.

Examples of chief complaints:

 Chest pain for 3 days.
 Swollen ankles for 2 weeks.
 Fever and headache for 24 hours.
 Pap smear needed.
 Physical examination needed for camp.

IV. History of present illness

 Gathering information relevant to the chief complaint, and the client's
problem, including essential and relevant data, and self-medical
treatment.

A. Components of Present Illness

 Introduction: "client's summary and usual health".
 Investigation of symptoms: "onset, date, gradual or sudden, duration,
frequency, location, quality, and alleviating or aggravating factors".
 Negative information.
 Relevant family information.
 Disability "affected the client's total life".

V. Past Health History

Purpose:
 (To identify all major past health problems of the client)
This includes:
 Childhood illness e.g. history of rheumatic fever.
 History of accidents and disabling injuries
 History of hospitalization (time of admission, date, admitting complaint,
discharge diagnosis and follow up care.
 32
 History of operations "how and why this done"
 History of immunizations and allergies.
 Physical examinations and diagnostic tests.

VI. Family History

The purpose:
 to learn about the general health of the client's blood relatives, spouse,
and children and to identify any illness of environmental genetic, or
familiar nature that might have implications for the client's health
problems.
 Family history of communicable diseases.
 Heredity factors associated with causes of some diseases.
 Strong family history of certain problems.
 Health of family members "maternal, parents, siblings, aunts, uncles…etc.".
 Cause of death of the family members "immediate and extended family".

EXAMPLE OF A GENOGRAM

VII. Environmental History

Purpose:
 "To gather information about surroundings of the client", including
physical, psychological, social environment, and presence of hazards,
pollutants and safety measures."
 33

VIII. Current Health Information

The purpose is to record major, current, health-related information:

 Allergies: environmental, ingestion, drug, other.

 Habits "alcohol, tobacco, drug, caffeine"
 Medications taken regularly "by doctor or self-prescription
 Exercise patterns.
 Sleep patterns (daily routine).
 The pattern life (sedentary or active)

IX. Psychosocial History

Includes :
 How client and his family cope with disease or stress, and how they respond
to illness and health.
 You can assess if there is psychological or social problem and if it affects
general health of the client.

X. Review of System (ROS)

 Collection of data about the past and the present of each of the client
systems.
 (Review of the client’s physical, sociologic, and psychological health status
may identify hidden problems and provides an opportunity to indicate client
strength and liabilities

ROS Checklist

 General. Usual weight, recent weight change, clothing that fits more tightly or
loosely than before; weakness, fatigue, fever.
 Skin. Rashes, lumps, sores, itching, dryness, color change; changes in hair or
nails; changes in size or color of moles.
 Head, Eyes, Ears, Nose, Throat (HEENT).
 Head: Headache, head injury, dizziness, lightheadedness.
 Eyes: Vision, glasses or contact lenses, last examination, pain, redness,
excessive tearing, double or blurred vision, spots, specks, flashing lights,
glaucoma, cataracts.
 Ears: Hearing, tinnitus, vertigo, earache, infection, discharge. If hearing is
decreased, use or nonuse of hearing aid.
 Nose and sinuses: Frequent colds, nasal stuffiness, discharge or itching, hay
fever, nosebleeds, sinus trouble.
 Throat (or mouth and pharynx): Condition of teeth and gums; bleeding gums;
dentures, if any, and how they fit; last dental examination; sore tongue; dry
mouth; frequent sore throats; hoarseness. Neck. Lumps, “swollen glands,”
goiter, pain, stiffness.
 Breasts. Lumps, pain or discomfort, nipple discharge, self-examination
practices.
 Respiratory. Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing,
pleurisy, last chest x-ray. You may wish to include asthma, bronchitis,
emphysema, pneumonia, and tuberculosis.
 Cardiovascular. “Heart trouble,” hypertension, rheumatic fever, heart murmurs,
chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, edema, past electrocardiographic or other cardiovascular
tests.
 Gastrointestinal. Trouble swallowing, heartburn, appetite, nausea. Bowel
movements, color and size of stools, change in bowel habits, rectal bleeding or
black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food
 34
intolerance, excessive belching or passing of gas. Jaundice, liver or gallbladder
trouble, hepatitis.
 Peripheral Vascular. Intermittent claudication; leg cramps; varicose veins; past
clots in veins; swelling in calves, legs, or feet; color change in fingertips or toes
during cold weather; swelling with redness or tenderness.
 Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or pain on
urination, hematuria, urinary infections, kidney stones, incontinence; in males,
reduced caliber or force of urinary stream, hesitancy, dribbling.
 Genital.
a. Male: Hernias, discharge from or sores on penis, testicular pain or masses,
history of sexually transmitted infections (STIs) or diseases (STDs) and
treatments, testicular self-examination practices. Sexual habits, interest,
function, satisfaction, birth control methods, condom use, problems.
Concerns about HIV infection.
b. Female: Age at menarche; regularity, frequency, and duration of periods;
amount of bleeding, bleeding between periods or after intercourse, last
menstrual period; dysmenorrhea, premenstrual tension. Age at menopause,
menopausal symptoms, postmenopausal bleeding. In patients born before
1971, exposure to diethylstilbestrol (DES) from maternal use during
pregnancy. Vaginal discharge, itching, sores, lumps, STIs and treatments.
Number of pregnancies, number and type of deliveries, number of abortions
(spontaneous and induced), complications of pregnancy, birth control
methods. Sexual preference, interest, function, satisfaction, problems
(including dyspareunia). Concerns about HIV infection.
 Musculoskeletal. Muscle or joint pain, stiffness, arthritis, gout, backache. If
present, describe location of affected joints or muscles, any swelling, redness,
pain, tenderness, stiffness, weakness, or limitation of motion or activity; include
timing of symptoms (e.g., morning or evening), duration, and any history of
trauma. Neck or low back pain. Joint pain with systemic features such as fever,
chills, rash, anorexia, weight loss, or weakness.
 Psychiatric. Nervousness; tension; mood, including depression, memory change,
suicide attempts, if relevant.
 Neurologic. Changes in mood, attention, or speech; changes in orientation,
memory, insight, or judgment; headache, dizziness, vertigo; fainting, blackouts,
seizures, weakness, paralysis, numbness or loss of sensation, tingling or “pins
and needles,” tremors or other involuntary movements, seizures.
 Hematologic. Anemia, easy bruising or bleeding, past transfusions, transfusion
reactions
 Endocrine. “Thyroid trouble,” heat or cold intolerance, excessive sweating,
excessive thirst or hunger, polyuria, change in glove or shoe size.

XI. Functional Assessment

 ADLs (Actvities of Daily Living)
 Sleep/rest
 Nutrition/problems with diet, weight
 Alcohol /Substance abuse
 Smoking history (in pack years)
 Coping difficulties
 Domestic/ child abuse

XII. Perception of Health

 How one defines health
 Views on one’s health status
 What are one’s expectations pertaining to health and health care
 35

Lesson 6
COLLECTING THE
OBJECTIVE DATA: The
Comprehensive
Physical Examination
(Introduction)
I. Physical Examination (PE)
 Goal is to identify variations from normal.
 Explain procedure first
 Head to Toe Assessment
 Unaffected areas before affected

PURPOSES OF THE PHYSICAL EXAMINATION:

1. To obtain baseline data about the client’s functional abilities.
2. To supplement, confirm, or refute data obtained in the nursing
history.
3. To obtain data that will help establish nursing diagnoses and
plans of care.
4. To evaluate the physiological outcomes of health care and thus
the progress of a client’s health problem.
5. To make clinical judgments about a client’s health status.
6. To identify areas for health promotion and disease prevention.

II. Preparing the Client

 The nurse should explain when and where the examination will take
place, why
it is important, and what will happen.
 Instruct the client that all information gathered and documented
during the assessment is kept confidential in accordance with the
Health Insurance Portability and Accountability Act (HIPAA). This
means that only those healthcare providers who have a legitimate
need to know the client’s information will have access to it.
 Health examinations are usually painless; however, it is important to
determine in advance any positions that are contraindicated for a
particular client.
 The nurse assists the client as needed to undress and put on a gown.
 Clients should empty their bladders before the examination. Doing so
helps them feel more relaxed and facilitates palpation of the abdomen
and pubic area. If a urinalysis is required, the urine should be collected
in a container for that purpose.

III. Preparing the Environment

 The time for the physical assessment should be convenient to both the
client and the nurse. The environment needs to be well lighted and the
equipment should be organized for efficient use.
 36
 A client who is physically relaxed will usually experience little
discomfort.
 The room should be warm enough to be comfortable for the client.
 Providing privacy is important. Most people are embarrassed if their
bodies are exposed or if others can overhear or view them during the
assessment.
 Culture, age, and gender of both the client and the nurse influence
how comfortable the client will be and what special arrangements
might be needed.
 Family and friends should not be present unless the client asks for
someone.

IV. Positioning
 37

V. Draping
 Drapes should be arranged so that the area to be assessed is
exposed
and other body areas are covered. Exposure of the body is
frequently
embarrassing to clients. Drapes provide not only a degree of
privacy
but also warmth. Drapes are made of paper, cloth, or bed linen.
VI. Instrumentation
 All equipment required for the health assessment should be clean,
in
good working order, and readily accessible. Equipment is
frequently set
up on trays, ready for use. Various instruments are shown in Table
30-3.
 38

VII. Methods of Examining (Assessment Techniques)

 Four primary techniques are used in the physical examination:
inspection,
palpation, percussion, and auscultation. These techniques

A. Inspection
 First technique used.
 What examiner sees, hears and smells.
 Observe symmetry.
 Close and careful visualization of the person as a whole and of
each body system
 Ensure good lighting
 Perform at every encounter with your client

B. Palpation
 Second technique using fingers and hands to touch.
 Purpose:
 Temperature, Texture, Moisture
 Organ size and location
 Rigidity or spasticity
 Crepitation & Vibration
 Position & Size
 Presence of lumps or masses
 Tenderness, or pain

TYPES OF PALPATION TECHNIQUE

 LIGHT PALPATION
 ½ to ¾ inches (1.5 to 2 cm)
 39

 DEEP PALPATION
 1 ½ to 2 inches (4 to 5 cm)
 Deep palpation is usually not done during a routine
examination and requires significant practitioner skill. It
is performed with extreme caution because pressure
can damage internal organs. It is usually not indicated
in clients who have acute abdominal pain or pain that is
not yet diagnosed.

 DEEP BIMANUAL PALPATION

 In deep bimanual palpation, the nurse extends the
dominant
hand as for light palpation, then places the finger
pads of the nondominant hand on the dorsal surface
of the distal interphalangeal joint of the middle three
fingers of the dominant hand (Figure 30–2 •).
 40

• Parts of the hands used during Palpation

a. Palmar Surface
b. Dorsal Surface
c. Ulnar Surface
 41

C. Percussion
 Third technique
 Tapping on skin surface which creates a vibration of underlying
structures. The vibration produces a sound, may aid in diagnosis.
 Assess underlying structures for location, size, density of underlying
tissue.
 42

Types

1. Direct

2. Indirect
 43

3. Blunt percussion

Uses of Percussion:

 Mapping out location and size of an organ

 Determining density (air, fluid, solid) of a structure
 Detecting superficial mass (up to 5 cm deep)
 Eliciting pain if underlying structure is inflamed
 Eliciting a DTR (Deep Tendon Reflex) using a percussion hammer

ACTIVITY: Applying Critical Thinking

Read the situation carefully then answer what is asked.
Write your answer in a separate sheet and send your answer
to your respective Clinical Instructor. Follow the templates
provided and see rubrics located in the appendix on how
your activity will be evaluated.

I. SITUATION:
 44

A 75-year-old woman is admitted to your unit for evaluation after being

found unconscious on the floor of her apartment. She is now awake but
moving slowly. Her vital signs are within normal limits.

1. In the hospital, it is unrealistic to expect to be able to spend an

uninterrupted 30 to 60 minutes with a single client performing
an admission assessment. Which three systems would have top
priority for her initial assessment and why?

2. While gathering relevant history data, what should you do if the

client answers with simple one-word answers or gestures?

3. Because the client may be in significant discomfort from her fall,

it is not easy for her to move about for the examination. How
might you organize your assessment to minimize her need to
change positions frequently?

4. If the client is unable to provide a detailed recent history, what

other sources of these data could you consider?

II. Choose an adult client from your community and make a Nursing
Health History using the format below.

I. Biographical Data
 Full name
 Address and telephone numbers
 Birth date and birth place.
 Sex
 Religion and race.
 Marital status.
 Social security number.
 Occupation (usual and present)
 Source of referral
 Usual source of healthcare.
 Source and reliability of information.
 Date of interview.

II. Reliability
III. Chief Complaint: “Reason For Hospitalization”.
IV. History of present illness (Using COLDSPA Mnemonic)
V. Past Health History
VI. Family History
VII. Environmental History

VIII. Current Health Information

IX. Psychosocial History
X. Review of System (ROS)

XI. Functional Assessment

XII. Perception of Health
 45
MODULE SUMMARY

In this module, you have learned about Health Assessment. You

have learned some medical terminologies and approved abbreviations.
You have also learned how to conduct history taking, interview, and
techniques in doing physical examination. In this module, role of a nurse
in health assessment is also introduced. Always observe bioethical
concepts and principles and nursing standards to protect and ensure
safety not only to your patients but also to yourself. Practice good and
comprehensive documentation. Most importantly, have a good
relationship and rapport between the health care team that caters the
needs of your patient.

To sum it up, this module has five (6) lessons. Lesson 1 discusses
the overview of Health Assessment. Lesson 2 includes The Nursing
Process. Lesson 3 discusses about Assessment. Interview and Health
History is discussed in Lesson 4. Lesson 5 is all about The Comprehensive
Adult Health History. Lesson 6 discusses about the Introduction of Adult
Health Assessment.

Congratulations! You have just studied this Module. You are

now ready to evaluate how much you have benefited from your
reading by
answering the summative test through google forms. Good Luck!!!
 46
CONGRATULATIONS!
You are now ready to move on to the
next module! God Bless!

REFERENCES

Dennison, R. D., Rosselli, J., & Dempsey, A. (2015). Evaluation Beyond

Exams in Nursing Education: Designing Assignments and Evaluating with
Rubrics. New York: Springer Publishing Company.

Potter, P. A., & Perry, A. G., (2018). Fundamentals of Nursing 9th Edition. Missouri:
Elsevier.

Nettina, S. M., (2010) Lippincott Manual of Nursing Practice 9 th Edition. Philadelphia:

Lippincott Williams and Wilkins

Udan, J. Q., (2021). Mastering fundamentals of Nursing Practice 4 th Edition. Philippines:

Educational Publishing House

Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s Fundamentals of
Nursing Concepts, Process, and Practice 10 th Edition. New Jersey: Pearson

Weber, J., & Kelly, J. (2014). Health Assessment in Nursing 5th Edition. Philadelphia:
Lippincott Williams and Wilkins

Bickley, l., & Szilagyi, P. (2017). Bate’s Guide To Physical Examination and History
Taking. Philadelphia : Lippincott Williams and Wilkins

APPENDIX A
RUBRICS FOR HEALTH HISTORY
Inadequate Fair Good Very good
effort 2 pts 4 pts 6 pts
0 pts

Part I- Student Student Student

Biographical provides no provides less Student includes all
Data biographical than 5 items of provides 5 to elements of
information. biographical 7 items of biographical
data. biographical data.
Includes all data.
pertinent
 47
objective data

Reason for
Seeking Care Fails to Provides a Provides a Provides a
provide a vaguely written clearly focused
focused statement for written clearly
Provides written reason/feelings statement for written
clearly written statement for about seeking reason/feelin statement
explanation for reason/feelin care. gs for and regarding the
patient gs about about patient
appointment seeking care. seeking care. reason/feelin
gs for and
about
seeking care.
Places reason
in quotations.
History of
Present Health Documentati Documentation Documentati Documentatio
Concern on is fails to address on addresses n correctly
inadequate all elements in all elements addresses
with gross detail or has with minor every
deficiencies significant grammatical, element of
in grammar, grammatical, spelling, or the
Includes
comprehensive spelling spelling, and /or word usage assessment
subjective data and/or word usage errors. having the
formatting errors. proper format
(word usage). with no
grammatical,
spelling, or
word usage
errors.

Medical/Family
Health History Documentati Documentation Documentati Documentatio
on is fails to address on addresses n correctly
inadequate all elements in all key addresses
with gross details or has elements every key
deficiencies significant with minor element of
Includes
in grammar, grammatical, grammatical the
comprehensive
spelling, spelling, and or errors, assessment
health history
and/or word word usage spelling, or having the
data
usage. errors. word usage proper format
errors. with no
grammatical,
spelling or
word usage
errors.

Environmental
History Documentati Documentation Documentati Documentatio
on is fails to address on addresses n correctly
inadequate all elements in all key addresses
with gross details or has elements every key
deficiencies significant with minor element of
Includes
in grammar, grammatical, grammatical the
comprehensive
spelling, spelling, and or errors, assessment
health history
and/or word word usage spelling, or having the
data
usage. errors. word usage proper format
errors. with no
 48
grammatical,
spelling or
word usage
errors.

Functional
Assessment Documentati Documentation Documentati Documentatio
on is fails to address on addresses n correctly
inadequate all elements in all key addresses
Includes with gross details or has elements every key
comprehensive deficiencies significant with minor element of
health history in grammar, grammatical, grammatical the
data spelling, spelling, and or errors, assessment
and/or word word usage spelling, or having the
usage. errors. word usage proper format
errors. with no
grammatical,
spelling or
word usage
errors.

Perception of
Health Documentati Documentation Documentati Documentatio
on is fails to address on addresses n correctly
inadequate all elements in all key addresses
with gross details or has elements every key
deficiencies significant with minor element of
Includes
in grammar, grammatical, grammatical the
comprehensive
spelling, spelling, and or errors, assessment
health history
and/or word word usage spelling, or having the
data
usage. errors. word usage proper format
errors. with no
grammatical,
spelling or
word usage
errors.

Total: 42 points

Review of Inadequate Meets Minimum Very Good

Systems 3 pts Standard 10 pts
10 pts 6 pts
Student provides Student provides a
limited review of Student provides comprehensive
Assess all systems systems adequate review review of systems
appropriately documentation. of systems documentation
using inspection, documentation that covers all
palpation and that covers systems with no
auscultation as majority of grammatical,
indicated. systems with spelling or word
Appropriately minimal usage errors.
assess all negative grammatical,
findings. <BR> spelling or word
Document all usage errors.
findings concisely
using appropriate
terminology.
Total: 10 points