Posted: October 13th, 2016
Using a simulated client that you have access to, usually the same volunteer you are using for your physical assessments/practice, conduct a health history and review of systems (ROS) interview per the guidance in Chapter 1 of your book. Conduct the health history and review of systems interview with cultural humility (Ball, Dains, Flynn, Solomon, & Stewart, 2015, pp. 21-29). You may want to use the documentation format on pages 621 to 624 to guide your interview, as the Problem-Oriented Medical Record is the format you will be using for document.
During your interview obtain the information for a pedigree (genogram) covering 3 generations—the interviewee’s generation as well as the prior and subsequent generations. If there are no subsequent generations (the interviewee does not have children or nieces/nephews, then collect information on the 2 prior generations). Be sure to use the international pedigree nomenclature (symbols) summarized in Figure 26-3 (Ball et al., 2015, p. 623). Your pedigree may not be hand written; however, it may be in an appendix or uploaded as a separate PowerPoint or pdf file.
Document the History in paragraph format, organized by headings as indicated on pages 621 through 622 of your text and including information as specified there. Do not use abbreviations such as WNL or WDP, but rather write out your findings.
• Identifying information
• Problems, allergies, medications, & immunizations (PAMI) list
• General client/patient information
• Source & reliability of information
• Chief concern/presenting problem
• History of present illness (choose only 1 current illness if more than one is shared)
• Family history summarize here and included the pedigree diagram as an appendix
• Personal and social history
• DENTAL HISTORY (even though not addressed here in your text)
Be sure to include all components described in your text for each of the above sections.
Review of Systems (ROS)
Remembering that the ROS does not include any physical examination, document your ROS of the following systems in your paper (pp. 622-624).
• General constitutional symptoms
• Skin, hair, & nails
• Head & neck
• Throat & Mouth
• Chest & lungs
• Heart and blood vessels
• Peripheral vasculature
• Mental health
Perform and document the following assessments on your volunteer.
• Functional assessment (p. 571)
• Muscles strength (pp. 511-512)
• Mini-cog assessment (p. 69)
• Provide a complete list of health problems identified. If no health problems were found provide a list of health promotion/risk reduction areas the patient identifies that they would like to work on.
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