Department of Nursing Grading Criteria for Complete Health Assessment Case Study Paper
Department of Nursing Grading Criteria for Complete Health Assessment Case Study Paper
Team #_____________________________Names:______________________________________________________________________________________Date: __________
Content Possible Points Student’s Score
1. Biographical Data, Source and Reliability of Information, Reason for Seeking Care are complete.
5
2. History of Present Illness is written in paragraph form.
15
3. Review of Systems (Subjective data)– discuss history of each system and use abbreviated format, not complete sentences: general, psychiatric, skin, hair, nails, lymph nodes, HEENT (head, eyes, ears, nose, mouth, throat), neck, blood, breasts, cardiovascular, respiratory, GI, GU, musculoskeletal, neurologic, endocrine
20
4. Physical Assessment: General Survey, Vital Signs, Height and Weight, Pain Assessment, BMI
10
5. Physical Examination (Objective Data)– Vital signs, general appearance, psychiatric, HEENT, neck, breasts, lymph nodes, pulmonary, cardiovascular, skin, nails, abdomen, genitourinary, pelvic, rectal, extremities, musculoskeletal, neurological (DTR’s, reflex grading, cranial nerve evaluation)
25
6. Medications – For each medication the client is taking fill out a Patient Education Sheet that includes
Why/How patient takes the medication
The 3 most common side effects & symptom(s) to report
Address patient medication related concerns
15
7. Health Promotion: State 3 areas where health promotion is needed for this patient. Provide specific examples of how you would educate this patient. Describe how these health promotion teachings fall in line with the Healthy People 2020 Objectives.
10
TOTAL
100
Note – Students may use the Complete Health Assessment form on pg.784 in the Jarvis textbook as a guide as a guide for write-up but using own
medication.
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