Health Assessment Check-Off Project Discussion
Health Assessment Check-Off Project Discussion
Complete the “Health Assessment Check-Off Project” template using a patient that you have previously worked with. Ensure that you have adequately completed the assessment steps and given a proper recommendation.
APA style is not required, but solid academic writing is expected.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
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Health Assessment Check-Off Project
Physical Exam Documentation
Chief Complaint:
History of Present Illness:
Past Medical History (Hx):
Past Surgical Hx:
Family Hx:
Social Hx:
Allergies:
Medications:
Review of symptoms by system:
Physical Exam:
Assessment:
Treatment Plan:
| Criteria | Percentage | 1: Unsatisfactory (0.00%) | 2: Less Than Satisfactory (80.00%) | 3: Satisfactory (88.00%) | 4: Good (92.00%) | 5: Excellent (100.00%) | Comments | Points Earned |
| Critera | 100.0% | |||||||
| Chief Complaint | 8.0% | A description of the chief complaint is not included. | A description of the chief complaint is incorrect or incomplete. | A description of the chief complaint is included but lacks details. | A description of the chief complaint is complete and lacks supporting details. | A description of the chief complaint is extremely thorough and includes substantial details. | ||
| History of Present Illness | 8.0% | A description of present history of illness is not included. | A description of present history of illness is incorrect or incomplete. | A description of present history of illness is included but lacks details. | A description of present history of illness is complete and lacks supporting details. | A description of present history of illness is extremely thorough and includes substantial details. | ||
| Past Medical History (Hx) | 8.0% | A description of past medical history is not included. | A description of past medical history is incorrect or incomplete. | A description of past medical history is included but lacks details. | A description of past medical history is complete and lacks supporting details. | A description of past medical history is extremely thorough and includes substantial details. | ||
| Past Surgical Hx | 8.0% | A description of past surgical history is not included. | A description of past surgical history is incorrect or incomplete. | A description of past surgical history is included but lacks details. | A description of past surgical history is complete and lacks supporting details. | A description of past surgical history is extremely thorough and includes substantial details. | ||
| Family Hx | 8.0% | A description of family history is not included. | A description of family history is incorrect or incomplete. | A description of family history is included but lacks details. | A description of family history is complete and lacks supporting details. | A description of family history is extremely thorough and includes substantial details. | ||
| Social Hx | 8.0% | A description of social history is not included. | A description of social history is incorrect or incomplete. | A description of social history is included but lacks details. | A description of social history is complete and lacks supporting details. | A description of social history is extremely thorough and includes substantial details. | ||
| Allergies | 8.0% | A description of allergies is not included. | A description of allergies is incorrect or incomplete. | A description of allergies is included but lacks details. | A description of allergies is complete and lacks supporting details. | A description of allergies is extremely thorough and includes substantial details. | ||
| Medications | 8.0% | A description of medications is not included. | A description of medications is incorrect or incomplete. | A description of medications is included but lacks details. | A description of medications n is complete and lacks supporting details. | A description of medications is extremely thorough and includes substantial details. | ||
| Review of Symptoms by System | 8.0% | A review of symptoms by system is not included. | A review of symptoms by system is incorrect or incomplete. | A review of symptoms by system is included but lacks details. | A review of symptoms by system is complete and lacks supporting details. | A review of symptoms by system is extremely thorough and includes substantial details. | ||
| Physical Exam | 8.0% | A description of the steps taken during the physical exam is not included. | A description of the steps taken during the physical exam is incorrect or incomplete. | A description of the steps taken during the physical exam is included but lacks details. | A description of the steps taken during the physical exam is complete and lacks supporting details. | A description of the steps taken during the physical exam is extremely thorough and includes substantial details. | ||
| Assessment | 8.0% | A description of the assessment steps is not included. | A description of the assessment steps is incorrect or incomplete. | A description of the assessment steps is included but lacks details. | A description of the assessment steps is complete and lacks supporting details. | A description of the assessment steps is extremely thorough and includes substantial details. | ||
| Treatment Plan | 8.0% | A description of the treatment plan recommended for the patient is not included. | A description of the treatment plan recommended for the patient is incorrect or incomplete. | A description of the treatment plan recommended for the patient is included but lacks details. | A description of the treatment plan recommended for the patient is complete and lacks supporting details. | A description of the treatment plan recommended for the patient is extremely thorough and includes substantial details. | ||
| Mechanics of Writing (includes spelling, punctuation, grammar, and language use) | 2.0% | Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is employed. | Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied. | Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed. | Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech. | The writer is clearly in command of standard, written, academic English. | ||
| Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style) | 2.0% | Sources are not documented. | Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors. | Sources are documented, as appropriate to assignment and style, although some formatting errors may be present. | Sources are documented, as appropriate to assignment and style, and format is mostly correct. | Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error. | ||
| Total Weightage | 100% |
Health Assessment Check-Off Project Discussion