DCE Health History With Clinical Reasoning RubricDO NOT WAIT UNTIL THE LAST MINUTE TO DO THIS ASSIGNMENT - IT IS TIME
CONSUMING.
Objectives
Demonstrate the ability to establish the parameters for a health interview
Begin and enhance use of effective techniques of communication
Modi...
DO NOT WAIT UNTIL THE LAST MINUTE TO DO THIS ASSIGNMENT - IT IS
TIME CONSUMING.
Objectives
Demonstrate the ability to establish the parameters for a health interview
Begin and enhance use of effective techniques of communication
Modify communication techniques as indicated by each patient’s developmental stage, special
needs, or cultural practices
Demonstrate facilitators of effective communication and identify/avoid blockers of
effective communication
Establish rapport and trust so the person feels accepted and thus free to share all relevant data.
Gather complete and accurate data about the person’s health state, including the
description and chronology of any symptoms of illness.
Teach the person about the health state so that the person can participate in identifying
problems.
Build rapport for a continuing therapeutic relationship; this rapport facilitates future
diagnoses, planning and treatment.
Begin teaching for health promotion and disease prevention.
(Jarvis, 2012)
Histories are a vital part of our nursing practice and having this knowledge will allow us to better
develop a plan of care for our patient. Nurses are known for our history taking expertise and
when to ask the appropriate questions to gather pertinent data.
I realize that in most settings we do not perform this extensive of an interview, although all of
this information is gathered in some form in almost all settings, whether we see it all or not. It
is there and we need to use this information to care for our patient.
Guidelines for the CHHx
In this assignment you will follow the nursing process and demonstrate your clinical reasoning:
A. Patient Interview
Interview Tina Jones to gather a thorough health history
Collect data to assess Ms. Jones’ condition
Educate and empathize to engage in effective therapeutic communication
Document data accurately, using professional terminology
B. Information Processing
Identify any applicable nursing diagnoses using evidence from the data you collected
Prioritize the identified diagnoses to differentiate immediate from non-
immediate care
1
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