N518 Module 1: The Health History and Interview- Shadow Health Assessment
N 518 Module 1: The Health History and Interview
The Health History and Interview- Shadow Health Assessment : This first discussion assignment is intended to help each student set a context for the course, establish expectations and goals for the course, and provide insights to the instructor enabling tailoring of the course to better fit the needs of the students. Replies to discussion questions must be well considered and scholarly.
Every course you take should provide the knowledge and skills useful in the real world. Not every course will directly link to every task that you perform in your life or current employment, but learning how to review data, develop data analysis, critical thinking, and writing skills are all needed to convince someone that you can think critically and solve problems. Your ability to pull together and leverage information, insights, and lessons from a number of disparate disciplines in novel ways could be precisely what is needed to stay ahead of your competition and give you a competitive edge.
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Your first task is to learn about the course and discover how the skills provided in this course are relevant to you. You will prepare for, post, and engage in a discussion with your classmates and your professor.
The Health History and Interview- Shadow Health
Welcome to Health Assessment
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Hello class: my name is, and I will be the instructor for this class. For more information on how to get a hold of me, please go under my profile for specific information. However, my email is: ***The best way to contact me though, is through the Private forum***
This course will focus on methods of health history taking, physical examination skills, documentation, and health screening. The course emphasizes the individual as the client, functional health patterns, community resources, and the teaching learning process. This course will take us through infancy to an older adult.
To find course material, go under your Dashboard, then you will see PATH. There are two links to find information regarding this course; course material and syllabus.
- The course material tab shows what textbook is used for this class.
- The syllabus will show what this course is, the assignments for the course, the topics of the course, the grading system, and how to refer to the student policy handbook. **there has been some problems downloading the syllabus, thus the PATH is also the syllabus…but 1 week and topic at a time.
Under your Assignments, will have the due date and the rubric posted to look at.
Under the Planner tab, assignments are listed along with the due dates. Clicking the collaborative reminder within the calendar tab will show the assignment, any information that is needed for the assignment, and give the rubric of how the assignment will be graded.
Please refer to all other announcements for Class Policies and Week 1 class.
Feel free to contact me anytime. I look forward to this 5 week journey with each of you
Assessment
Module 1: Discussion Question
Start by reading and following these instructions:
You are responsible for minimally at least 3 posts for each question in your discussion boards; your initial post and reply to two of your classmates. Your initial post(s) should be your response to the questions posed in the Discussion Question. You should research your answer and cite at least one scholarly source when appropriate, and always use quality writing. The discussion board is never a place to use text language or emoticons. You will also be asked to respond to your classmates. This is designed to enhance the academic discussion around the topic. It is all right to disagree with something posted by another, however your responses should always be thoughtful and respectful and reflect your opinions professionally.
Discussion Question:
Complete a comprehensive risk assessment for a friend or family member. Please do not use the patient’s name or identifiers. Discuss your findings. Then, reflect on your interview and discuss which parts went well and which parts you will change the next time you complete a risk assessment.
Your initial posting should be 200 to 300 words in length and utilize at least one scholarly source other than the textbook. Please reply to at least two classmates. Replies to classmates should be at least 100 words in length. To properly “thread” your discussion posting, please click on REPLY.
When you are ready for the discussion, do the following:
- Click on the discussion link above.
- Start your answer by clicking “Start a New Thread” button with the title of your answer and the body of text following the guidance above.
- To properly post your answer, please click on the “Post” button.
- After posting your contribution, you must read what others have posted, reply to at least two of those posts, and respond (when appropriate) to those you have responded to you.
To reply to a classmate’s post:
- Click on the title of another student’s post.
- Click “Reply to Thread” and type your response to the student.
- Click the “Post” button to post your reply.
Module 1: Assignment
Remember to submit your work following the file naming convention FirstInitial.LastName_M01.docx. For example, J.Smith_M01.docx. Remember that it is not necessary to manually type in the file extension; it will automatically append.
Start by reading and following these instructions:
1. Quickly skim the questions or assignment below and the assignment rubric to help you focus.
2. Read the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.
3. Consider the course discussions so far and any insights gained from it.
4. Create your Assignment submission and be sure to cite your sources if needed, use APA style as required, and check your spelling.
Assignment:
Exercises:
- Complete the Shadow Health tutorial
- Complete the Shadow Health History assessment.
Professional Development
- Write a reflection essay of your experience with the Shadow Health virtual assessment. At least two scholarly sources in addition to your textbook should be utilized. Please be sure to address each of the following prompts:
- What went well in your assessment?
- What did not go so well? What will you change for your next assessment?
- What findings did you uncover?
- What questions yielded the most information? Why do you think these were effective?
- What diagnostic tests would you order based on your findings?
- What differential diagnoses are you currently considering?
- What patient teaching were you able to complete? What additional patient teaching is needed?
- Would you prescribe any medications at this point? Why or why not? If so, what?
- How did your assessment demonstrate sound critical thinking and clinical decision making? What could you change to make it better?
SUBJECTIVE DATA COLLECTION
Subjective Data Collection: 63 of 104 (60.6%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Found:
Indicates an item that you found.
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Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Finding:
Established chief complaint
-
Finding:
Reports pain
(Found)
Pro Tip: Beginning your conversation with your patient by asking an open-ended question is a best practice for gauging your patient’s general condition.Example Question:
How severe is the pain? -
Finding:
Reports open foot wound
(Found)
Pro Tip: If a patient mentions pain, it’s important to determine what specifically is causing her pain.Example Question:
What’s causing your pain?
History of Present Illness
Finding:
Asked for details about the pain
-
Finding:
Describes the pain as throbbing
(Available)
Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.Example Question:
Can you please describe the pain? -
Finding:
Describes the pain as sharp when she attempts to stand
(Found)
Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.Example Question:
What is the pain like when you stand on your foot? -
Finding:
Initial injury occurred 1 week ago
(Available)
Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute.Example Question:
When did the pain start? -
Finding:
Pain has increased in the past 2 days
(Available)
Pro Tip: Finding out how the patient’s pain has changed will give you insight into the acceleration of infection.Example Question:
How has the pain changed over time? -
Finding:
Reports feeling pain radiating into ankle
(Available)
Pro Tip: Asking about where else the patient’s pain radiates can help determine the progression of infection.Example Question:
Does the pain radiate anywhere else? -
Finding:
Pain prevents bearing weight on foot
(Found)
Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care.Example Question:
Can you bear weight on your foot?
Finding:
Asked to rate pain on a scale
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Finding:
Rates present pain at a 7 out of 10
(Found)
Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care.Example Question:
Can you rate the pain on a scale of 0 to 10?
Finding:
Clarified location of wound
-
Finding:
Confirmed that right foot is injured
(Found)
Pro Tip: Confirming which extremity an injury is located is a best practice for your patient’s safety.Example Question:
Which foot is in pain? -
Finding:
Confirmed that wound is on the plantar surface of her foot
(Available)
Pro Tip: Confirming where a wound is located ensures you are aware of your patient’s biggest complaint.Example Question:
Where is the wound?
Finding:
Determined details of the injury
-
Finding:
Scraped foot on a cement step
(Found)
Pro Tip: Discovering how an injury happened helps to assess your patient’s risk factors for injury.Example Question:
How did your injury happen? -
Finding:
Reports mild ankle injury
(Available)
Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury.Example Question:
Did you injure anything besides your foot? -
Finding:
Was not drinking at the time of the injury
(Available)
Pro Tip: Finding out if alcohol is involved in an injury can give you insight into a patient’s potential substance abuse, and can uncover aggravating factors.Example Question:
Did you have any alcoholic drinks before your injury? -
Finding:
Was not wearing shoes at the time of injury
(Found)
Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances.Example Question:
Were you wearing shoes when you fell?
Finding:
Asked about the assessment of the injury at the ER