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Tina Jones Comprehensive Assessment | self reflection Study Guide

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Self-Reflection Explicitly describe the tasks you undertook to complete this exam. Activity Time: 20 min Objective Data Collection Documentation Plan My Exam Student Response: A comprehensive as... sessment is a complete, all-encompassing, in-depth assessment that includes a complete health history and physical assessment. Components of the health history are the patient's personal history of illness, as well as their family medical history, including any current or prior treatments, surgeries, risk factors, and medications or supplements. In addition, it should include details of other aspects of health, such as the patient’s perception of their health, health beliefs, coping mechanisms, support systems, and functional status. The first question I asked was for Tina to verify her name and date of birth. This is a safety check that assures the assessment I am about to conduct, is on the right patient. It also helps me to determine if this patient is alert to self. Another important question that I started my interview process with was asking the patient the reason for her visit, and if she had any health concerns she would like to discuss. This helps focus the attention on the patient and what he or she needs or hopes to get out of the visit, and also helps guide the interview. Other questions were based on the components of the health history mentioned earlier. For example, I asked Tina how she felt she was doing, to get insight to her perception of health, which can help identify areas of that Tina may need further education on. In addition, I asked Tina what her medical history was, what (if any) medications (OTC, prescribed or supplements) she was currently taking and the reason for taking them, and the dose and frequency. Aside from Tina’s health I asked questions about her personal life, such as who she lived with, what her new job would be, relationship status, and what she enjoyed doing for fun. [Show More]

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