Requirements to Follow/grading rubric

To recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual values, and developmental) and objective data (physical examination findings) in planning and implementing nursing care.

To reflect on the interactive process that takes place between the nurse and an individual while conducting a health assessment and a physical examination.

Rubric

NR304 RUA: Health History and Physical Assessment Guidelines (Sept20)

NR304 RUA: Health History and Physical Assessment Guidelines (Sept20)

Criteria Ratings Pts

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This criterion is linked to a Learning OutcomeHealth History: Subjective Data

Required criteria

1. Demographic data

2. Reason for care (why they are in the facility)

3. Present illness (PQRST of current illness)

4. Perception of health

5. Past medical history (including medications, allergies, and vaccinations and immunizations)

6. Family medical history

7. Review of systems