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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:

  1. 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.
  2. 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.
  3. 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

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