helath history help!!!!!

  1. can someone pls. help me do my health history?!!!!!
    I do not know how to format my paper or what i have gotten from my pt.
    if anyone has their old one or a website i can use as an example that would be great!
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    About Gift.Fr.Virgo12

    Joined: Jul '06; Posts: 58; Likes: 1


  3. by   Daytonite
    there are lots of links to internet information on collecting data at this thread:
    this link, in particular (which is posted somewhere on that thread),
    http://medicine.ucsd.edu/clinicalmed/introduction.htm has two examples of how to write up your history and physical findings. this is a medical school site.

    not sure what you are looking for in formatting your paper. unless your instructors have given you specific instructions, i guess you are on your own. you can look at care plan samples to see how students have presented their assessment data to get an idea of how they did that. many of those links are on the two careplan sticky threads of the student forums, but i'll list them here for your convenience.

    http://www.rncentral.com/careplans/contents.html - from rn central's care plan corner. here are care plans for 49 basic nursing problems. also includes a template for a blank form you can print out. each care plan gives you the language needed to write the nursing diagnosis statement, suggestions for outcomes, and nursing interventions for that particular problem.

    http://www.nursing-care-plan.com/generic.pdf - this is a 4-page care plan template. a very nice feature of this template is that in the section for the physical assessment and review of systems (ros) it lists topics under each body system that you should question or put attention on.

    http://www.nursing-care-plan.com/diabetes.pdf - this is a 3-page care plan for a patient with diabetes. the nursing diagnosis chosen was imbalanced nutrition: more than body requirements r/t excessive intake of nutrition aeb weight of 260 lbs. the care plan includes the physical assessment and review of systems, a prioritized list of actual and potential problems which are stated in terms of nursing diagnoses, short and long term goals, nursing interventions, rationales and evaluation.

    http://www.childbirths.com/euniversi...are%20plan.htm - two sample care plans from e-university. one of fluid volume excess and the other on risk for potential injury (aspiration). both include objective and subjective assessment data, outcomes, nursing interventions, rationale and evaluation.

    http://www-isu.indstate.edu/mary/carep.htm - sample care plan for potential for injury (aspiration)

    http://www-isu.indstate.edu/mary/carep2.htm - sample care plan for fluid volume excess

    http://home.hiwaay.net/~theholt1/nurs1100/careplan.htm - this is a care plan guideline from the nursing department of fairleigh dickinson university with instructions on composing your diagnosis, goals, interventions and evaluations. includes links on suggestions for conducting interviews with patients and gordon's 11 functional patterns.

    http://listserv.acsu.buffalo.edu/archives/carepl-l.html - this is an archives of student nursing care plans at the state university of new york, buffalo. you will need to check out the links to the various care plans to find out what each care plan is about as they are not given in the links.

    http://www.cnsonline.org/www/archive/ms/ms-07.txt - sample care plan for an ms patient

    http://nursesintraining.8m.com/cp_copd.htm - sample care plans for a patient with copd from the nurses in training web site