Running head: HEALTH HISTORY AND PHYSICAL
ASSESSMENT 1
Health History and Physical Assessment
Hannah Gabon
Chamberlain College of Nursing
NR304 Health Assessment II
Professor Christa Stigler
August 2019
Hannah Gabon
Hannah Gabon
Hannah Gabon
Health History Assessment and Physical Assessment 2
Health History Assessment and Physical Assessment
I conducted a health assessment on a 70 year’s old male patient
from California who was

suffering from hypertension. The patient is currently taking
diuretics medication which cause
increase urination. The medication also causes his sodium and
fluids levels to drop thus lowering
patient’s blood pressure so it’s imperative to balance and
monitor vital sign. The patient stated
that he was moderately satisfied with the care received in the
facility. The patient is a smoker and
stated his concern of experiencing vision issues and heart
failure, which prompted immediate
care for this patient.
Before being admitted to the hospital, patient stated that he was
experiencing chest pain
which was not ending nor was it increasing in exertion. He did
not experience nausea, vomiting,
dizziness or unconsciousness. He took some pain killers with no
relief but managed to sleep in
the morning. After beginning his daily activities, the pain
increased and was then rushed to the
hospital. He underwent some test that clarified that he was
suffering from hypertension. When I
reviewed patient past medical records, it showed that he has
condition at early age and minor

surgery. I reviewed the patient's cardiovascular, eyes, nose,
throat, respiratory system, and his
immune system. Patient immunization was also put into
consideration when I reviewed his past
medical record as this will be helpful planning for his care.
Thirty years ago, the patient developed a diffuse rash after he
was injected with penicillin
which he was allergic to, but it was not known. Some of his past
health operations includes:
chest pains in 1990 and minor surgery on his left arm. He has a
medical case of pneumonia at an
early age, which did not take long to heal. The patient was
raised by his stepmother since his
mother passed away 72 years ago from heart failure. His father
passed on 68 years ago after
committing suicide in his house. His wife died 10 years ago
after struggling with tuberculosis for
Hannah Gabon
98440000000099648
what condition?
Health History Assessment and Physical Assessment 3
a long period of time. He has six children; two are deceased
after both suffered from

hypertension. He has 20 grandchildren and 10 great-
grandchildren. His family have history of
hypertension but no known history of tuberculosis.
The patient’s physical assessment findings were that he had an
elevated blood pressure of
125/80 which shows that it was high, but it is controllable. I
also found that he had a unique heart
sound which was as a result of an enlarged heart. The patient
had a swollen neck vein which was
probably caused by heart failure. He also had some
abnormalities in the blood vessels behind the
eyes. He has no clinical cardiovascular disease or signs of
hypertension-related target- organ
damage. The patient had narrowed kidney arteries and endocrine
disorders. The patient had no
respiratory problems, but his lungs sounded as if it was
congested. His peripheral pulses were
present and strong, and his thorax was under the normal shape.
Through health teaching topics, students can acquire
knowledge, skills and positive
attitude about health. From these teaching, students can learn
about physical, mental emotional
and mental health. This enables students to enhance and

maintain their health in preventing
diseases and minimize risky habits (Don, 2000). Through this
teaching, student acquire positive
changes and behaviors that reduce the risk of the student being
around alcohol, tobacco, and
other drugs. Through this teaching, the community becomes
aware of how to prevent chronic
diseases as well as how to maintain healthy nutrition and
prevent obesity (Vadurro, 2018).
Through the finding in the scholarly articles, there has been
great awareness about chronic
diseases and how they can be prevented and managed by
integrating such as nutrition and how to
deal with stress. The findings also advance the understanding of
how the mind and body
strategies impact health and well-being. The findings mainly
focus on the treatment of diseases,
Hannah Gabon
98440000000099648
under??????????
Hannah Gabon
98440000000099648
How do you know?
Hannah Gabon

98440000000099648
they were congested.
Hannah Gabon
98440000000099648
nurse's are not qualified to determine this.
Hannah Gabon
98440000000099648
How would you know this?
Health History Assessment and Physical Assessment 4
this has helped in finding treatment for diseases and the
productiveness of pharmacologic
strategies in treating and controlling the illnesses (Green LW.
Et al. 1980)
The interrelationship of psychological developmental, cultural
and psychosocial
consideration impacts a person's experiences and definition of
health and illnesses. This
relationship guides the day to day lifestyle of people. It
determines if people in given community
access to health care and their responses to disease pain and
disabilities. Through the integration
of individual strength and collaborative resources, the proposed
health teaching will be well
appreciated in the community since through these strengths they

will improve the population-
level health outcome by supporting the proposed health teaching
which may lead to a sustainable
environmental transition in different parts of the community
which are associated with health.
The patient was not willing to share the information with me as
he considered it as a
distraction. To comfort patient, I began by explaining to him the
importance of the interview. I
explained to him the information was required for learning
purpose which helped in convincing
him that the interview was not aimed at interfering with his
privacy since the information will
not be shared by any third party. I explained to him the benefits
of speaking about his health
conditions and with the information shared, it will be easier to
come up with a better medical
plan that will help a medical professional care for his needs. I
explained to him that if he shared
his health information, I will be able to explain to him the
living habits that he was expected to
adapt based on his condition. When conducting my next
physical examination, I will ensure that
I implement the four techniques which involves inspections,

palpation, percussion, and
auscultation.
Hannah Gabon
98440000000099648
This is not correctly formatted.
Hannah Gabon
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What went well? What information had you wished you had
obtained.
Hannah Gabon
This section is very vague. I am not sure if his unwillingness to
share was a barrier but if so how did you overcome it to get the
information you needed?
Hannah Gabon
Did he consent to the assessment? I am unclear on this.
Health History Assessment and Physical Assessment 5
References:
Don Nutbeam. (2000, September) Health literacy as a public
health goal: a challenge for
contemporary health education and communication strategies
into the 21st
century, Health Promotion International, 15(3), Pp. 259–267.
Retrieved from

https://doi.org/10.1093/heapro/15.3.259
Vadurro Marcy. (2018, February 8). The Importance of Health
Education. Retrieved from
https://www.snhu.edu/about-us/newsroom/2018/02/importance-
of-health-education
Green LW. Et al. (1980). Health education planning: a
diagnostic approach. Retrieved from
https://www.popline.org/node/499039
https://doi.org/10.1093/heapro/15.3.259
https://www.snhu.edu/about-us/newsroom/2018/02/importance-
of-health-education
https://www.popline.org/node/499039
8/7/2019 Grades for Hannah Gabon: Health Assessment II-
Stigler
https://chamberlain.instructure.com/courses/45424/grades 2/3
Close Rubric
NAME DUE SCORE OUT OF
Week 7: RUA:
Health History
and Physical
Assessment
Supplemental
Assignments

Aug 11 by 11:59am 100
Assessment by Christa Stigler
Health History and Physical Assessment
CRITERIA RATINGS PTS
Health History
and Physical
Examination
Comments
Hannah,
You did not address the client's perception of health. The
review of systems did not include them all and was very vague
(what were the results? What did the patient tell you?).
Developmental, cultural, psychosocial, and
collaborative resources were not addressed.
37 / 50 pts
Needs
Assessment
Comments
Hannah,
Although you discussed some teaching points for patients in
general, you did not address speci�c needs for this patient nor
how he could incorporate them into his life. You also only had
one journal article and the rubric required 2.
5 / 20 pts

Re�ection 15 / 20 pts
Writing Style
and Format
Comments
Hannah,
You had several APA formatting issues and issues with
grammar. You can use grammarly in the library to help with this
and [email protected] for APA formatting assistance. You also
had several areas of the rubric either not addressed or
not addressed fully. Please see embedded comments throughout
paper for more detailed feedback.
5 / 10 pts
Total Points: 62
50 to >45 pts
Outstanding or Highest Level of
Performance
Thoroughly presents a health history
narrative that includes a detailed description
of all the following components •
Demographic data • Reason for care •
Present illness • Perception of health • Past

medical history • Family medical history •
Review of systems • Developmental
considerations • Cultural considerations •
Psychosocial considerations • Collaborative
resources Thoroughly presents a physical
exam narrative that includes a detailed
description of all the following components
HEENT • Neurological system • Neck •
Respiratory system • Cardiovascular system
• Gastrointestinal system • Musculoskeletal
system • Peripheral vascular system •
Integumentary system integrated in exam of
all systems where appropriate Information is
presented in a clear, organized, and
professional manner.
45 to >41 pts
Very Good or High Level of Performance
One of the key elements of the health history

narrative is not presented or lacks suf�cient
detail. • Demographic data • Reason for care
• Present illness • Perception of health • Past
medical history • Family medical history •
Review of systems • Developmental
considerations • Cultural considerations •
Psychosocial considerations • Collaborative
resources One of the key elements of the
physical exam is not presented or lacks
suf�cient detail. HEENT • Neurological
system • Neck • Respiratory system •
Cardiovascular system • Gastrointestinal
system • Musculoskeletal system •
Peripheral vascular system • Integumentary
system integrated in exam of all systems
where appropriate Information is presented
in a clear, organized, and professional manner.
41 to >37 pts

Competent or Satisfactory Level of
Performance
Two of the key elements of the health history
narrative are not presented or lack suf�cient
detail. • Demographic data • Reason for care
• Present illness • Perception of health • Past
medical history • Family medical history •
Review of systems • Developmental
considerations • Cultural considerations •
Psychosocial considerations • Collaborative
resources Two of the key elements of the
physical exam are not presented or lacks
suf�cient detail. • HEENT • Neurological
system • Neck • Respiratory system •
Cardiovascular system • Gastrointestinal
system • Musculoskeletal system •
Peripheral vascular system • Integumentary
system integrated in exam of all systems

where appropriate Information is not
presented in a clear, organized, and
professional manner.
37 to >0 pts
Poor, Failing or Unsatisfactory Level of
Performance
Three or more of the key elements of the
health history narrative are not presented or
lack suf�cient detail. • Demographic data •
Reason for care • Present illness • Perception
of health • Past medical history • Family
medical history • Review of systems •
Developmental considerations • Cultural
considerations • Psychosocial considerations
• Collaborative resources Three or more of
the key elements of the physical exam are not
presented or lack suf�cient detail. • HEENT •
Neurological system • Neck • Respiratory

system • Cardiovascular system •
Gastrointestinal system • Musculoskeletal
system • Peripheral vascular system •
Integumentary system integrated in exam of
all systems where appropriate Information is
not presented in a clear, organized, and
professional manner.
20 to >18 pts
Outstanding or Highest Level of
Performance
Accurately identi�es two health education
needs for this individual and provides at least
three factors that may, positively or
negatively, in�uence the person’s ability to
incorporate the health teaching to improve
his or her well-being. References two peer-
reviewed journal articles that provide
evidence-based support for the health

teaching; APA format (most current edition)
used to list the sources.
18 to >16 pts
Very Good or High Level of Performance
Accurately identi�es a health education need
for this individual and provides at least two
factors that may, positively or negatively,
in�uence the person’s ability to incorporate
the health teaching to improve his or her well-
being. References two peer-reviewed journal
articles that provide evidence-based support
for the health teaching but does not use
appropriate APA format (most current
edition) to list the sources.
16 to >15 pts
Competent or Satisfactory Level of
Performance
Accurately identi�es a health education need

for this individual and provides at least two
factors that may, positively or negatively,
in�uence the person’s ability to incorporate
the health teaching to improve his or her well-
being. References one peer-reviewed journal
articles that provides evidence-based support
for the health teaching but does not use
appropriate APA format (most current
edition) to list the sources.
15 to >0 pts
Poor, Failing or Unsatisfactory Level of
Performance
Accurately identi�es a health education need
for this individual and poorly or minimally
applies one or more factors that may,
positively or negatively, in�uence the person’s
ability to incorporate the health teaching to
improve his or her well-being. No references

are submitted or, if they are used, they have
three or more types of errors in APA format
(most current edition) to list the sources.
20 to >18 pts
Outstanding or Highest Level of
Performance
Thoughtfully appraises the individual
holistically. Re�ection includes a detailed
response to all the following questions. • How
did your interaction compare to what you’ve
learned? • What went well? • What barriers
to communication did you experience? • How
did you overcome them? • Were there
unanticipated challenges to the interview? •
Was there information you wished you’d
obtained? • How will you alter your approach
the next time? Key and relevant information is
presented in suf�cient detail and is clear and

organized.
18 to >8 pts
Very Good or High Level of Performance
Thoughtfully appraises the individual
holistically. One of the following questions is
not presented or lacks suf�cient detail. • How
did your interaction compare to what you’ve
learned? • What went well? • What barriers
to communication did you experience? • How
did you overcome them? • Were there
unanticipated challenges to the interview? •
Was there information you wished you’d
obtained? • How will you alter your approach
the next time? Key and relevant information is
presented in suf�cient detail and is clear and
organized.
8 to >7 pts
Competent or Satisfactory Level of

Performance
Broadly appraises the individual. Two of the
following questions are not presented or lack
suf�cient detail. • How did your interaction
compare to what you’ve learned? • What
went well? • What barriers to communication
did you experience? • How did you overcome
them? • Were there unanticipated challenges
to the interview? • Was there information
you wished you’d obtained? • How will you
alter your approach the next time? Key and
relevant information is presented in
insuf�cient detail but is clear and organized.
7 to >0 pts
Poor, Failing or Unsatisfactory Level of
Performance
Broadly appraises the individual. Three or
more of the following questions are not

presented or lack suf�cient detail. • How did
your interaction compare to what you’ve
learned? • What went well? • What barriers
to communication did you experience? • How
did you overcome them? • Were there
unanticipated challenges to the interview? •
Was there information you wished you’d
obtained? • How will you alter your approach
the next time? Key and relevant information is
presented in insuf�cient detail and is not clear
or organized.
10 to >9 pts
Outstanding or Highest Level of
Performance
Student presents information using clear and
logical language. Grammar, spelling, and
punctuation are free of errors. APA sixth
edition was used to guide the style and format

of this paper.
9 to >8 pts
Very Good or High Level of Performance
Student presents information using clear and
logical language. Grammar, spelling, and
punctuation have two or fewer types of
errors, or there is no more than one error in
APA sixth-edition formatting.
8 pts
Competent or Satisfactory Level of
Performance
Student presents information using clear and
logical language. Grammar, spelling, and
punctuation have three types of errors, or
there are no more than two errors in APA
sixth-edition formatting.
8 to >0 pts
Poor, Failing or Unsatisfactory Level of

Performance
Information is unclear and dif�cult to follow.
Grammar, spelling, and punctuation have
three or more types of errors, or there are
more than three errors in APA sixth-edition
formatting.
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Hannah Gabon
Hannah Gabon
Hannah Gabon

Hannah Gabon
NR 304 RUA Grading Rubric and Grading Criteria V2.docx
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REQUIRED UNIFORM ASSIGNMENT GUIDELINES
THE HEALTH HISTORY AND PHYSICAL EXAMINATION
PURPOSE
As you learned in NR302, before any nursing plan of care or
intervention can be implemented or
evaluated, the nurse conducts an assessment, collecting
subjective and objective data from an
individual. The data collected are used to determine areas of
need or problems to be addressed by the
nursing care plan. This assignment will focus on collecting both
subjective and objective data,
synthesizing the data, and identifying health and wellness
priorities for the person. The purpose of the
assignment is twofold.
• To recognize the interrelationships of subjective data
(physiological, psychosocial, cultural and
spiritual values, and developmental) and objective data
(physical examination findings) in
planning and implementing nursing care

• To reflect on the interactive process that takes place between
the nurse and an individual while
conducting a health assessment and a physical examination
COURSE OUTCOMES
CO1: CO1. Explain expected client behaviors while
differentiating between normal findings,
variations and abnormalities. (PO1)
CO 2: Utilize prior knowledge of theories and principles of
nursing and related disciplines to
integrate clinical judgment in professional decision-making and
implementation of
nursing process while obtaining a physical assessment. (POs 4,
8)
CO 3: Recognize the influence that developmental stages have
on physical, psychosocial,
cultural, and spiritual functioning. (PO 1)
CO 4: Utilize effective communication when performing a
health assessment. (PO 3)
CO5: Demonstrate beginning skill in performing a complete
physical examination using the techniques of
inspection, palpation, percussion, and auscultation. (PO
2
CO 6: Identify teaching/learning needs from the health history
of an individual. (POs 2, 5)
CO 7: Explore the professional responsibilities involved in
conducting a comprehensive health assessment
and providing appropriate documentation. (PO 6, 7)

DUE DATE
Please see the Course Calendar.
TOTAL POINTS POSSIBLE 100 points
PREPARING THE ASSIGNMENT
There are four graded parts to this assignment: (1) Obtain a
health history and conduct a physical
examination on an individual of your choosing (not a patient),
(2) compile a health education needs
assessment, (3) self-reflection, and (4) writing style and format.
Instructions for each part follow.
NR 304 RUA Grading Rubric and Grading Criteria V2.docx
10_16 SMa 4 Revised 11/05/18 EL/css
Health History Assessment and Physical Assessment (50 points)
well as your textbook for explicit
details about each category, complete a health history and
physical examination on an
individual. You may choose to complete portions of this
assignment as you obtain the health
history and perform the physical examination associated with
NR304. Please be sure to avoid the use of any identifiers in
preparing the assignment. Students

may seek input from the course instructor on securing an
individual for this assignment. Keep
notes on each part of the health history and physical
examination as you complete them so that
you can refer to the notes as you write the paper.
1. Subjective Data—Health History Components to Be Included
• Demographic data
• Reason for care (why they are in the facility)
• Present illness (PQRST of current illness)
• Perception of health
• Past medical history (including medications, allergies, and
vaccinations and
immunizations)
• Family medical history
• Review of systems
• Developmental considerations
• Cultural considerations
• Psychosocial considerations
• Presence or absence of collaborative resources (community,
family, groups, and
healthcare system)
***REMEMBER: Make notes of the health history findings,
ensuring that you have addressed all of the

components listed here. Students are also encouraged to take
notes about their experiences while
conducting the health history for reference when creating the
assignment, particularly the reflection section.
2. Objective Data—Physical Exam Components to Be Included
ou will conduct a series of
physical exams that includes the
them to reference as you write
system exam. Remember,
assessment of the integumentary system is an integral part of
the physical exam and should be
o HEENT (head, eyes, ears, nose, and throat)
o Neck (including thyroid and lymph chains)
o Respiratory system
o Cardiovascular system

NR 304 RUA Grading Rubric and Grading Criteria V2.docx
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o Neurological system
o Gastrointestinal system
o Musculoskeletal system
o peripheral vascular system
***REMEMBER: Make notes of the physical examination
findings, ensuring that you have addressed all of the
components listed on the Return Demonstration Checklist.
Students are also encouraged to take notes
about their experiences while conducting the physical
examination for reference when creating the
assignment, particularly the reflection section.
Needs Assessment (20 points)
1. Based on the health history and physical examination
findings, determine at least two health
education needs for the individual. Remember, you may identify
an educational topic that is
focused on wellness.

2. Select two peer-reviewed journal articles that provide
evidence-based support for the health
teaching needs you have identified.
Reflection (20 points)
Nurses use reflection to, mindfully and intentionally, examine
our thought processes, actions,
and behaviors in order to better evaluate our patients’ outcomes.
You have interviewed an
individual, conducted a head-to-toe physical assessment, and
identified at least two health
teaching needs. You have also located within the literature
evidence-based support for the
teaching that will be used to address the individual’s health
education needs. As you formulate
your findings in writing within this assignment, it is time to
turn your attention inward. The final
element of this assignment is to write a reflection that describes
your experience.
1. Be sure your reflection addresses each of the following
questions.
a. How did this assignment compare to what you’ve learned and
expected?
b. What enablers or barriers to communication did you
encounter when performing a
health history and physical exam? How could you overcome
those barriers?

c. Were there any unanticipated challenges encountered during
this assignment?
What went well with this assignment?
d. Was there information you wished you had available but did
not?
e. How will you alter your approach to a obtaining a health
history and conducting a
physical examination the next time?
Writing Style and Format (10 points)
Your writing should reflect your synthesis of ideas based on
prior knowledge, newly acquired
information, and appropriate writing skills. Scoring of your
written communication is based on
proper use of grammar, spelling, and APA sixth-edition
formatting, as well as how clearly your
thoughts and reasoning are expressed in writing.
Documentation of Findings or How to Write the Paper
NR 304 RUA Grading Rubric and Grading Criteria V2.docx
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Using Microsoft Word, create a double-spaced document. The
paper should be formatted according

to APA sixth-edition guidelines for the title page, running head,
and reference page. The use of
headings is required for this paper. All portions of this
assignment should be included within the
paper, including the reflection.
1. Begin by writing one to two paragraphs describing the
individual’s stated condition of health
medications and allergies. Also, include any of the following
information that may be pertinent:
demographic data, perception of health, past medical history,
vaccinations and immunizations,
family medical history, review of systems, developmental
considerations, cultural
considerations, psychosocial considerations, and the presence or
absence of resources from the
community, family, groups, or the healthcare system.
2. Write one paragraph describing the physical assessment
findings, ensuring proper terminology
is used to describe any abnormal or unusual findings.
3. Write one paragraph discussing (1) the rationale for the
selection of the health teaching topics
and (2) how the findings in the scholarly articles (identified in
the needs assessment portion of
the assignment and properly cited) were used to develop the
health teaching topics to promote
the individual’s health and wellness status.
4. Write one paragraph discussing (1) how the interrelationships
of physiological, developmental,

cultural, and psychosocial considerations will influence, assist,
or become barriers to the
effectiveness of the proposed health education and (2) a
description of the impact of the
individual’s strengths (personal, family, and friends) and
collaborative resources (clinical,
community, and health and wellness resources) on the proposed
teaching.
5. Write one paragraph describing your reflection of this
assignment from a holistic point of view.
Consider the following areas: Include the environment, your
approach to the individual, time of
day, and other features relevant to therapeutic communication
and to the interview process.
You may find your textbook helpful in providing a description
of therapeutic communication and
of the interview process. Be certain to address the questions
listed above in the reflection
instructions.
NR 304 RUA Grading Rubric and Grading Criteria V2.docx
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Chamberlain College of Nursing NR304 Health Assessment II
DIRECTIONS AND GRADING CRITERIA

Category Points % Description
Health
History and
Physical
Assessment
50 50 Conducts a comprehensive health history and physical
exam
1. Subjective data: demographic data; reason for care; present
illness; perception of health; past medical history; family
medical
history; review of systems; developmental considerations;
cultural considerations; psychosocial considerations; and
collaborative resources.
2. Objective data: HEENT; neurological system, respiratory
system,
cardiovascular system, neck; gastrointestinal system;
musculoskeletal system; and peripheral vascular system.
Provides a written narrative that includes the following
1. One to two paragraphs describing stated condition of health,
medications, and allergies. Also includes the following
information: demographic data, perception of health, past
medical history, vaccinations and immunizations, family
medical
history, review of systems, any developmental considerations,
cultural considerations or psychosocial considerations, presence
or absence of resources from the community, family, groups, or
from the healthcare system

2. One paragraph describing: the findings of the physical
examination
3. One paragraph discussing (1) the rationale for the selection
of the
health education topics and (2) how the findings in the scholarly
articles were used in support of the health teaching topic to
promote or improve the individual’s health and wellness status.
4. One paragraph discussing (1) how the interrelationships of
physiological, developmental, cultural, and psychosocial
considerations influence (assist or become barriers to the
effectiveness) the proposed health education and (2) provide a
description of the impact of the individual’s strengths (personal,
family, and friends) and collaborative resources (clinical,
family,
community, and health and wellness resources) on the proposed
nursing teaching.
Needs
Assessment
20 20 1. Identifies two health education needs for the individual
based on
the health history and physical examination findings and two
peer-
reviewed journal articles providing evidence-based support for
the
identified health teaching needs
2. APA sixth-edition formatting used for in-text and reference
page

citations
Chamberlain College of Nursing NR304 Health Assessment II
NR 304 RUA Grading Rubric and Grading Criteria V2.docx
10_16 SMa 5 Revised 11/05/18 EL/css
Reflection 20 20 Reflects on the interaction with the
interviewee holistically. Considers
the interaction in its entirety: includes the environment, the
approach to
the individual, time of day, and other features relevant to
therapeutic
communication and the interview process. The reflection should
address
each of the following questions.
at you’ve learned and
expected?
experience? How did you overcome the barriers?
interview or performing the physical examination? What went
well?

Writing Style
and Format
10 10 Writing should reflect your synthesis of ideas based on
prior
knowledge, newly acquired information, and appropriate writing
skills.
Scoring of your work in written communication is based on
proper use
of grammar, spelling, and how clearly you express your
thoughts and
reasoning in writing. Proper use of APA sixth-edition style and
format
throughout this paper is required.
Total 100 100

NR304 Health Assessment II Chamberlain College of Nursing
NR 304 RUA Grading Rubric and Grading Criteria V2.docx
10_16 SMa Revised 11/05/18 EL/css 4
GRADING RUBRIC
Assignment
Criteria
Outstanding or Highest Level of
Performance
A (92–100%)
Very Good or High Level of
Performance
B (84–91%)

Competent or Satisfactory Level
of Performance
C (76–83%)
Poor, Failing or Unsatisfactory
Level of Performance
F (0–75%)
Health
History and
Physical
Examination
(50 points)
Thoroughly presents a health
history narrative that includes
a detailed description of all the
following components
care

considerations
considerations
Thoroughly presents a
physical exam narrative that
includes a detailed description
of all the following
components
HEENT
One of the key elements of the
health history narrative is not
presented or lacks sufficient
detail.

considerations
osocial considerations
One of the key elements
of the physical exam is not
presented or lacks sufficient
detail.
HEENT
• Neurological system
• Neck
• Respiratory system
• Cardiovascular system
• Gastrointestinal system
Two of the key elements of the
health history narrative are not
presented or lack sufficient
detail.

ew of systems
considerations
Two of the key elements of the
physical exam are not presented
or lacks sufficient detail.
• HEENT
• Neurological system
• Neck
• Respiratory system
• Cardiovascular system
• Gastrointestinal system
• Musculoskeletal system
Three or more of the key
elements of the health history
narrative are not presented or
lack sufficient detail.

considerations
es
Three or more of the key
elements of the physical exam
are not presented or lack
sufficient detail.

NR304 Health Assessment II Chamberlain College of Nursing
NR 304 RUA Grading Rubric and Grading Criteria V2.docx
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entary system
integrated in exam of all
systems where
appropriate
Information is presented in a
clear, organized, and
professional manner.
46-50 points

• Musculoskeletal system
• Peripheral vascular system
• Integumentary system
integrated in exam of all
systems where appropriate
Information is presented in a
clear, organized, and
professional manner.
42-45 points
• Peripheral vascular system
• Integumentary system
integrated in exam of all
systems where appropriate
Information is not presented in a
clear, organized, and
professional manner.
38-41 points
integrated in exam of all
systems where appropriate

Information is not presented in a
clear, organized, and
professional manner.
0–37 points
Needs
Assessment
(20 Points)
Accurately identifies two health
education needs for this
individual and provides at least
three factors that may, positively
or negatively, influence the
person’s ability to incorporate
the health teaching to improve
his or her well-being.
References two peer-reviewed
journal articles that provide
evidence-based support for the
health teaching; APA format
(most current edition) used to
list the sources.
19-20 points
Accurately identifies a health
education need for this
individual and provides at least

two factors that may, positively
or negatively, influence the
person’s ability to incorporate
the health teaching to improve
his or her well-being.
References two peer-reviewed
journal articles that provide
evidence-based support for the
health teaching but does not use
appropriate APA format (most
current edition) to list the
sources.
17-18 points
Accurately identifies a health
education need for this
individual and provides at least
two factors that may, positively
or negatively, influence the
person’s ability to incorporate
the health teaching to improve
his or her well-being.
References one peer-reviewed
journal articles that provides
evidence-based support for the
health teaching but does not use
appropriate APA format (most
current edition) to list the
sources.
16 points

Accurately identifies a health
education need for this
individual and poorly or
minimally applies one or more
factors that may, positively or
negatively, influence the
person’s ability to incorporate
the health teaching to improve
his or her well-being.
No references are submitted or,
if they are used, they have three
or more types of errors in APA
format (most current edition) to
list the sources.
0–15 points
Reflection
(20 Points)
Thoughtfully appraises the
individual holistically. Reflection
Thoughtfully appraises the
individual holistically. One of the
following questions is not
Broadly appraises the individual.
Two of the following questions
Broadly appraises the individual.
Three or more of the following

NR304 Health Assessment II Chamberlain College of Nursing
NR 304 RUA Grading Rubric and Grading Criteria V2.docx
10_16 SMa Revised 11/05/18 EL/css 6
includes a detailed response to
all the following questions.
compare to what you’ve
learned?
communication did you
experience?
them?
challenges to the interview?
wished you’d obtained?
approach the next time?

Key and relevant information is
presented in sufficient detail and
is clear and organized.
19-20 points
presented or lacks sufficient
detail.
compare to what you’ve
learned?
communication did you
experience?
them?
challenges to the interview?
wished you’d obtained?
approach the next time?
Key and relevant information is
presented in sufficient detail and
is clear and organized.

17-18 points
are not presented or lack
sufficient detail.
compare to what you’ve
learned?
communication did you
experience?
you overcome
them?
challenges to the interview?
wished you’d obtained?
approach the next time?
Key and relevant information is
presented in insufficient detail
but is clear and organized.
8 Points
questions are not presented or
lack sufficient detail.

compare to what you’ve
learned?
communication did you
experience?
rcome
them?
challenges to the interview?
wished you’d obtained?
approach the next time?
Key and relevant information is
presented in insufficient detail
and is not clear or organized.
0–7 points
Writing
Style and
Format
(10 points)
Student presents information
using clear and logical language.
Grammar, spelling, and

punctuation are free of errors.
APA sixth edition was used to
guide the style and format of this
paper.
10 points
Student presents information
using clear and logical language.
Grammar, spelling, and
punctuation have two or fewer
types of errors, or there is no
more than one error in APA
sixth-edition formatting.
9 points
Student presents information
using clear and logical language.
Grammar, spelling, and
punctuation have three types of
errors, or there are no more than
two errors in APA sixth-edition
formatting.
8 points
Information is unclear and
difficult to follow. Grammar,
spelling, and punctuation have
three or more types of errors, or
there are more than three errors
in APA sixth-edition formatting.
0–7 points
Total Points Possible = 100 points