The purpose of this assignment is to provide students with an opportunity to familiarize with Shadow Health and complete portions of a Health History Interview. Students will utilize data collecting techniques, therapeutic communication skills, and provide patient education.It is estimated that 70-90% of diagnostic decisions are made based on the health history, making this an important skill for nurses. This assignment aligns with the following course objectives:
Perform the essential skills of a comprehensive health assessment including creating a detailed health history and performing a physical examination. (BSN Student Learning Outcomes 1, 2, 4, & 6)
Assess the influence of social, cultural, and spiritual values on the patient’s health beliefs and practices. (BSN Student Learning Outcomes 1, 2, & 6)
Instructor Note: This assignment may take a little bit of time. Please review the instructions and grading rubric below. You must ask at least 90% of the questions listed on the interview guide in order to get full points for the subjective data collection section. The following activity guide may help you as you move through this assignment: Health History Assignment.docx
Instructions: This activity will guide you through a Shadow Health assignment and what you will be doing moving with each individual Systems Exams assignments. You will also be completing a portion of a Health History for subjective data collection and documentation.
1.) Access the Health History assignment in Shadow Health.
2.) Complete the following as part of the exam:
-Introduce yourself to your patient and explain what you will be doing.
-Use the interview guide to keep track of what needs to be asked. Note: The interview guide will not be available for the final project, so be sure to take/keep notes.
-When you are finished with your interview, conclude the exam by summarizing the interview and and letting your patient what you will do once you leave the room.
-Document your findings in the documentation area. If you are unfamiliar with documenting a Review of Systems, please see the resources in Module 1.
3.) Be sure to click on “End Exam” when you are completely finished with the assignment. Check the gradebook on Shadow Health to make sure that you have a recorded grade. If the assignment is listed as “In Progress” in your gradebook, your instructor cannot see it! If you have finished the assignment and still see this, please contact Shadow Health Support.
There is no file submission for this assignment. The instructor will review the assignment in Shadow Health.
Competency Exemplary Satisfactory Needs Improvement Unsatisfactory Total
60 pts 55pts 50 pts 45 pts
Subjective Data Collection >90% of the subjective data elements covered in Health History Interview 80-89% of the subjective data elements covered in the Health History interview 76-79% of the subjective data elements covered in the Health History Interview <76% of the subjective data elements covered in the health history interview /60
20 pts 17 pts 15pts 13pts
Patient Communication Communication with the patient is clear and concise. Rapport is established on introduction and the nurse signals the conclusion of the exam with concluding statements. Communication with the patient is mostly clear and concise. Nurse introduced self to patient, and explained the assessment. No conclusion to the exam was given. Communication with the patient is unclear – there are more than 7 questions that need to be rephrased to the patient. There may not be an introduction to the patient or conclusion to the exam. Communication is largely unprofessional or rude. Large amounts of medical jargon used. There may or may not be an introduction at the beginning of the exam or conclusion at the end. /20 pts
Documentation Documentation for all areas of the health history interview is accurate, clear and concise. Appropriate terminology used with appropriate details provided – there is no excessively wordy documentation. Documentation is mostly clear, accurate and concise, with medical terminology used most of the time. Some areas of documentation may be wordy. Documentation is inaccurate with lack of appropriate terminology used. Documentation may be excessively wordy or at least one area lacking documentation. Documentation is unclear and lacking in appropriate terminology. More than one area lacking documentation. May be excessively wordy.
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