Health history and physical examination
RUA Paper Outline
This outline is to help provide a framework for writing your paper. Please review the guidelines for this paper before using this outline.
Your paper will be graded based on the rubric provided within the assignment guidelines. It would be to your best benefit to review the guidelines BEFORE beginning your paper. There is an 8 page maximum, including the cover and reference pages.
Write a paper using the headers below. Include information provided as an outline for writing your paper.
I. Health History:
One paragraph:
• Demographics: Introduce your client/patient with initials (Example: “K.B.”) (USE OF FULL NAME IS PROHIBITTED AND A VIOLATION OF PRIVACY). Include race, occupation (include type of work, NOT their exact workplace), where they live, and age.
• Perception of Health: What are your client’s beliefs about health? How healthy are they? How does their health affect their behavior?
• Past Medical History: Do they have any medical diagnoses? Have they had any procedures? Include the year. What medications do they take (OTC medications should be included)?
*MUST include at least 1 medication and list details (dosage, frequency, etc)** Do they have any allergies? If so, what is the reaction? Are they up-to-date on immunizations?
Second paragraph
• Family Medical History: Do their close relatives have a significant medical history?
• Collaborative Resources: What/who do they have in the community to assist with their health? Do they attend church? Do they have a life coach, mentor, personal trainer, etc? Do they have a family member who assists with their health?
II. Review of Systems:
A review of systems includes SUBJECTIVE data only. Physical assessments should NOT be performed. Use your text book to ask detailed questions about signs and symptoms for each body system.
List denials and confessions of signs and symptoms. 1-2 sentences for each body system should suffice. Explore all any admission of signs or symptoms further. Use your book for examples of questions to ask your client to assess for signs and symptoms of the following body systems:
• Integumentary
• Head, Neck, Lymphatics
• Eyes, Ears, Nose, Throat, and Mouth
• Respiratory
• Cardiovascular
• Neurological
• Gastrointestinal
• Musculoskeletal
• Peripheral vascular
III. Developmental, Cultural, and Psychosocial Considerations
• Developmental: What are some developmental considerations for your client’s age group?
• Cultural: How does culture or tradition affect this person’s health?
• Psychosocial: Which Erikson stage is the client in? How does the stage affect their needs?
IV. Objective Data:
• Write out your physical exam in complete sentences. Be sure to use professional terminology.
• Refer to the course textbook and notes from lab for detailed components of each system exam.
V. Health Education Needs:
Based on the health history and physical examination findings, determine at least two health education needs for the individual. Select two peer-reviewed journal articles (published within the last 5 years) that provide evidence-based support for the health teaching needs you have identified.
• Write one paragraph discussing (1) the rationale for the selection of the health teaching topics and (2) how the findings in the scholarly articles (identified in the needs assessment portion of the assignment and properly cited) were used to develop the health teaching topics to promote the individual’s health and wellness status.
• Write one paragraph discussing (1) how the interrelationships of physiological, developmental, cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health education and (2) a description of the impact of the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) on the proposed teaching.
VI. Reflection:
• Describe the environment, your approach to the individual, and time of day of Health History Interview
• How did your interaction compare to what you have learned?
• What went well?
• What barriers to communication did you experience?
o How did you overcome them?
o What will you do to overcome them in the future?
• Were there unanticipated challenges to the interview?
• Was there information you wished you had obtained?
• How will you alter your approach next time?
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