Individual Client Health History and Examination (A Direct Care Experience)
n this assignment, you will be completing a health assessment on an older adult. To complete this
assignment, do the following:
1.Perform a health history on an older adult. Students who do not work in an acute setting may
“practice” these skills with a patient, community member, neighbor, friend, colleague, or loved
one. (If an older individual is not available, you may choose a younger individual).
2.Complete a physical examination of the client using the “Individual Health History and
Examination Assignment” resource. Use the “Functional Health Pattern Assessment” resource as a
guideline to assist you in completing the template.
3.Document findings of complete physical examination in Situation-Background-Assessment-
Recommendation (SBAR) format. Refer to the sample SBAR Template located on the National Nurse
Leadership Council website
athttps://www.ihs.gov/nnlc/includes/themes/newihstheme/display_objects/documents/resources/SBARTEMP
LATE.pdf as a guide.
4.Document the findings of the physical examination in the assessment worksheet.
5.Using the “Individual Health History and Examination Assignment” resource, provide the physical
examination findings summary with planned interventions for the client. Include any community
services in the interventions.
APA format is not required, but solid academic writing is expected.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become
familiar with the expectations for successful completion.
