HA3004: Comprehensive Health History Module 2 Pre-Assessment
HA3004: Comprehensive Health History Module 2 Pre-Assessment
HA3004: Comprehensive Health History Module 2 Pre-Assessment
Permalink:
PRACTICING DOCUMENTATION TECHNIQUES
Module Pre-Assessments are your opportunity to practice applying module content before final submission of your Competency Assessment. In this Competency, you will be completing your Competency Assessment in the Shadow Health platform, so for your Pre-Assessment, you will practice your documentation skills. HA3004: Comprehensive Health History Module 2 Pre-Assessment
View the following prompts and write a response. When you are finished, compare your answer to the optimal answer provided in the Pre-Assessment Optimal Response document.
Maria is conducting a patient health history on James, a 32-year-old teacher. Maria is asking James health history interview questions about his skin.
Maria: Good morning, James. I am Maria and will be your nurse today. What brings you in?
James: Good morning, Maria. Nice to meet you. Not much, I am just here for my regular checkup.
Maria: Okay, good. I am going to ask you some questions about your skin to get started.
James: Sure.
Maria: Has your skin changed in color recently?
James: No. I have not had any changes in the color of my skin.
Maria: Good. Have you had any changes in the moles on your skin?
James: No, I know that I have several moles, but none of them look any different from my last checkup 3 months ago. I have a mole on my left arm that I always thought was quite large, but it has not changed since I was a teenager.
Maria: Okay. How about any dryness or redness?
James: I am not experiencing any dryness or redness, thankfully.
Maria: Good. Any itching or rashes?
James: Nope. My skin is fine. Overall, I would say it was quite normal.
Maria: Okay, good. I am just notating this on the chart.
Provide an example of documentation that Maria would write when reviewing James’s skin during the health history.
Today is August 12, 2017, and Chris is performing an annual checkup on Stacey, a 43-year-old librarian. Chris is asking Stacey health history interview questions about her eyes and eyesight:
Chris: Do you have any difficulty seeing?
Stacey: Oh, I would say my eyes and eyesight are okay, I guess.
Chris: What do you mean by okay? Do you have any difficulty seeing things on a normal basis?
Stacey: No, I see fine, I don’t have any vision problems.
Chris: Do you have any blurred vision?
Stacey: I start to see blurry when reading for more than an hour or two.
Chris: How long ago did the blurred vision begin?
Stacey: About a month or so ago.
Chris: What do you do when you have the blurry vision?
Stacey: I rest them for an hour or so and the blurriness goes away.
Chris: Do you have any headaches or eye pain with the blurred vision?
Stacey: No.
Chris: Do you have any blind spots?
Stacey: No.
Chris: Do you have any eye pain?
Stacey: I do not experience any eye pain.
Chris: Any double vision?
Stacey: No.
Chris: Do your eyes ever swell?
Stacey: No.
Chris: Do they ever get red?
Stacey: No.
Chris: Have you ever had eye surgery or injury?
Stacey: No.
Chris: Do you use contacts and/or glasses?
Stacey: No.
Chris: When was your last vision check?
Stacey: Earlier in the year, February.
Chris: Any history of cataracts?
Stacey: No.
Chris: Any family history of eye problems?
Stacey: My great grandmother had cataracts.
Provide an example of documentation that a nurse would write when reviewing Stacey’s eyes during the health history.
Mark is conducting a health history interview on Sidney, a 35-year-old accountant. Mark is asking Sidney health history interview questions about his ears and hearing. Sidney provides the following response:
Sidney: Any history of ear ache?
Mark: I had a couple as a kid, but not many, and no issues as an adult.
Sidney: Do you ever have ear pain?
Mark: No.
Sidney: Have you ever had any injury to your ears?
Mark? No.
Sidney: Do you have any discharge or liquid from your ears?
Mark? No.
Sidney: Do you feel you have a lot of ear wax?
Mark: No. One time I did have to have it cleaned out at the doctor’s office, but only the one time.
Sidney: Do you feel you have any difficulty hearing sounds or normal conversation?
Mark: No. I feel I hear clearly.
Sidney: Have you ever had ringing in the ears?
Mark: No.
Sidney: Do you ever have dizziness?
Mark: No.
Sidney: When was the last time you had your hearing checked?
Mark: Probably as a kid in school.
Provide an example of documentation that a nurse would write when reviewing Sidney’s ears during the health history. HA3004: Comprehensive Health History Module 2 Pre-Assessment
Leave a Reply
Want to join the discussion?Feel free to contribute!