The focus of this assignment is on communicating details within the written client record.
The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.”
Directions
1. Find an adult who is not related to you who is willing to let you take a health history.
2. Download the NR305_Milestone1_Form from Doc Sharing. You will type your answers directly into this Word document. Your paper does NOT need to follow APA formatting; however, you are expected to be clear in your communication by using correct medical terminology, grammar, and spelling.
3. Remember this is a health history, not a physical assessment.Avoid words like frequently, improved, increased, decreased, good, poor, normal, or WNL as they may have different meanings for different people. Instead, document the specific data that led you to these conclusions, e.g., 3x/day instead of “frequently,” or consuming 4 servings of vegetables/day instead of “increased” vegetable servings.
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1034 words
| Reason for seeking care: | Among the main reasons for seeking treatment was that he was experiencing blurred vision and could not see well. He also developed some serious abdominal pain and started vomiting whenever he ate. |
| Health patterns: | He was a generally healthy person but could loss and gain weight over time and this was followed by rapid gain of the weight at different times. |
| Health goals: | Among his health goals, is to eat food that is healthy to their bodies so as to make sure that he is always reducing the chances of getting sick for him. |
