Training needs assessment ( Easy assignment)April 9, 2021
Health history and care plans
Assume you are interviewing a 65 year old African American womanAll documents need to be submitted in doc or docx format.Health History and Narrative summary need to be one document.Genogram can be submitted as separate document.PLEASE NOTE : This is part one of two and care plans would be done in a later assignment. Keep that in mind.Biographical DataDate/Time:Initials:Address:Source of Information: DOB:Age:Gender:Race:Marital Status:Ethnic Identity/Culture:Religion:Occupation:Health Insurance (Type/Coverage):LIVING ARRANGEMENTS:Number in household:Designated Caregiver: Home Conditions:?Clean ? Unclean Safety:?Good ?Fair ?Poor Hygiene:?Good ?Fair ?PoorComments: (Identify potential risks)Present Health or Illness:VITAL SIGNS:TEMP:Source:PULSE:Source: BPSite: RespirationRhythm: Pain Score Height (ft/in) Weight (lbs)(kgs)Health Beliefs and Practices, health patternsMedications: (Be sure to include OTC and Herbals, in addition to prescription medications)Current Medications Name: Dose Schedule Prescribing PhysicianACTIVITIES OF DAILY LIVING:ACTIVITY INDEPENDENT NEEDS ASSISTANCE DEPENDENT RECOMMENDATIONS/COMMENTSFeedingAmbulatingTransfer BedTransfer ToiletTransfer TubGroomingOral hygieneDressingBathingFood preparationShoppingMedicationsFinancesAccess ER servicesPast Medical History (PMH)CHRONIC CONDITIONS: (Year diagnosed, treatment, status, managing PCP)ALLERGIES:Medications:Foods:Environmental:Other:COMMENTS:IMMUNIZATIONS:• Are childhood/adolescent up to date: Yes No• Immunizations in past year:• Adverse Reaction to immunization: Yes No• If yes describe:Surgical History: Year, Procedure, (Physician and Institution, if knownSEXUAL HISTORYAny concerns:For females: Age at Onset of Menses/MenarcheFamily History:• Immediate Family• Extended family• Complete your family history utilizing the following link and create a Genogram for your client. https://familyhistory.hhs.gov/fhh-web/home.actionFor optimal assignment credit, please take a screen shot or copy and submit electronically as a separate attachment with this assignment.Psychosocial History• Occupation History• Education• Financial Background• Roles and Relationships• Family• Social Structure/Emotional Concerns• Self-Concept• SpiritualityReview of Body Systems (ROS)This is an interview about current or significant past medical issues/concerns (Head to Toe) that may impact planning of care.• Skin, Hair, and Nails• Head Neck and Lymphatic• Eyes• Ears, nose, Mouth, and Throat• Respiratory• Breast and Axillae• Cardiovascular• Peripheral Vascular• Abdomen• Urinary• Male/Female Reproductive• Musculoskeletal• NeurologicList any Safety Concerns:Nursing Narrative Note:
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