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July 15th, 2021
History Taking Project (100 pts.)
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Objectives: At the completion of this project students will be able to:
- Develop a proper patient history interview by:
- Discussing the need for acquiring and documenting the patient’s chief complaint.
- Determining a potential need for exam requisition modification.
- Detailing the necessary patient history questions.
- Incorporating the Sacred Seven Elements of obtaining a clinical history.
Assignment: Review the PPT on patient history taking and complete the following:
Assignment Details:
- You have been assigned to perform a PA, Oblique, and Lateral hand x-ray exam on a 53 year old male patient named Wilhelm Conrad Roentgen.
- Describe how you will conduct proper patient identification and a patient history interview. Be sure to include the Sacred Seven Elements of obtaining a patient history.
- Discuss what would be necessary if the exam requisition does not match the history obtained from the patient.
Assignment Submission Details: Document the Data Collection Process – Set up your interview to include:
Assignment Requirements:
- Microsoft Word Document – size 12 font
- Minimum Length – 1 page, maximum length 2 pages
Grading Rubric (100 pts.):
| Grading Rubric | ||||
|
Criteria |
Not Met (1 –14 ) |
Met (15 – 18) |
Exceeded (19 – 20) |
Score |
| Understanding of Need for Documentation of Chief Complaint | No or minimal expressed understanding of documentation | Expressed understanding of need for documentation ofchief complaint | Describes in full detail and demonstrates clear understanding of the need for documentation of chief complaint | |
| Requisition Modification | No or minimaldiscussion of modification of requisition | Discusses in some detail the modification needed and reason for modification | Explains in full detail the modification needed and the reasons for the modification | |
| Patient History Questions | Does not list the patient history questions asked | Lists the patient history questions | Lists the patient history questions and explains relevance of questions | |
| Patient Response/Relation to Chief Complaint | No or minimal understanding of importance of patient response correlation to the chief complaint | Demonstrates understanding of importance of patient response correlation to the chief complaint | Demonstrates clear and detailed understanding of importance of patient response correlation to the chief complaint | |
| Sacred Seven Elements of the Clinical History | 0 – 2 sacred seven elements included | 3 – 5 sacred seven elements included | All sacred seven elements included | |
| Comments: | Total: | |||
Requirements: 1 page
