Students will demonstrate knowledge of interviewing skills, the components of a health history, recording the history data, and assigning three priorities

Subject

-Criteria

Possible Points

Patient Demographics

-Gender, age, ethnicity, and other social demographics as indicated (self-pay, Insurance)

5

Chief Complaint 

-Use the patient’s own words—one or more symptoms or concerns cause the patient to seek care.

-Elaborate on the chief complaint; describes how each symptom developed.

I-ncludes the patient’s thoughts and feelings about the illness.

5

History of Present Illness

-Appropriate dimensions of cardinal symptoms are listed (including location, severity, quality, setting, chronology, aggravating/alleviating, and associated manifestations)

-HPI narrative flows smoothly in a logical fashion

-For those who favor mnemonics, the 8 dimensions of a medical problem can be easily recalled using OLD CARTS (
Onset, 
Location/radiation, 
Duration, 
Character, 
aggravating factors, 
Relieving factors, 
Timing and 
Severity).

10

Past Medical History

-Lists childhood illnesses 

-Lists adult illnesses with dates for at least three categories: medical, surgical, and psychiatric.

-Medication, Allergies

-Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety.

5

Current Health Status

-Summary of general health status related to the present illness.

5

Family History

Narrative and Genogram

to an external site.

-Outlines or diagrams of age and health or age and cause of death of siblings, parents, grandparents, and children.

-Documents the presence or absence of specific illnesses in the family (e.g., hypertension, coronary artery disease)

-The family pedigree shows at least three generations and involves the use of standardized symbols, which mark individuals affected with a specific diagnosis to allow for easy identification.

10

Risk assessment based on family history

-Family history of a known or suspected genetic condition

-Ethnic predisposition to certain genetic disorders

-Consanguinity (blood relationship of parents)

-Multiple affected family members with the same or related disorders

-Earlier than expected age of onset of disease

-Diagnosis in less-often-affected sex

10

Past Surgical History

-Were they ever operated on, even as a child? 

-What year did this occur? 

-Were there any complications? 

5

Social History

-Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur?

-Do they drink alcohol? If so, how much per day and what type of drink?

-Any drug use, past or present, should be noted. 

-Work, family, friends, community support systems, 

5

Sexual Activity

-Do they participate in intercourse? With persons of the same or opposite sex? 

-Are they involved in a stable relationship? 

-Do they use condoms or other means of birth control? 

-Married? The health of the spouse? Divorced? Past sexually transmitted diseases? 

-Do they have children? If so, are they healthy? Do they live with the patient?

5

Work/Hobbies/Other

-What sort of work does the patient do? 

-Have they always done the same thing? Do they enjoy it? 

-If retired, what do they do to stay busy? Any hobbies?

5

Review of systems (ROS)

-Documentation of the presence or absence of common symptoms related to each major body system.

-Consider asking a series of questions going from “head to toe.”

-The questions asked to reflect an array of standard and critical clinical conditions (heart disease, diabetes, arthritis)

-These disorders would only be recognized if the patient were explicitly prompted.

· Format

· General/skin/sleep

· HEENT 

· Respiratory 

· Cardiovascular 

· Musculoskeletal 

· Endocrine 

· Gastrointestinal and Urinary 

· Neuro/psyc

10

Prevention and Health Promotion

-At least one prevention activity.

-At least three health promotion recommendations.

10

APA Guidelines & Writing Style

APA (title page, margins, page numbers, headings, subheadings, citations); spelling; writing straightforward, concise, and professional.

10

Total

100