3.
The completed Health History, Genogram and SOAPER Problems Write-Up are the polished version of your interview on your selected client. You will identify Actual and
Risk Problems. For two of the identified problems, you will write a SOAPER note for each using nursing diagnosis and a minimum of three nursing interventions for each of the nursing diagnosis (**Must have reference cited using APA format). If not handed in on due date—it is considered late: 5 points off for each day late. This interview is to be scheduled and conducted between each student and a selected client. The selected client is to be a well elderly client, age 50 or older (AARP defines an older adult beginning at age 50).
Guidelines for Health History, Genogram, Nursing Diagnoses and SOAPER Write-Up and
Weekly In-Class Physical Examination Write-Up (PS 98-06)
The history and physicals are designed to give you practice in eliciting and writing history and physical examination findings logically and accurately for each body system.
OBJECTIVES:
1.To be able to obtain a health history
2. To be able to accurately record the history elicited
3.To accurately identify actual and risk problems based on elicited client information
4. To be able to accurately perform and record physical examination findings (weekly in lab period)
5. To be able to design a family genogram
GENERAL INFORMATION: a. OUT-of-CLASS—Health History, Genogram and SOAPER

1.You are to download the electronic version of the Health History which is located in the N312
Syllabus section on Beachboard. This is the exact same Health History in your Jarvis Student
Workbook pages 27-34. You will use your Jarvis textbook Chapter 4, pages 49-59, as a guide to each set of questions. You will type your responses for each section underneath each section.-the electronic copy can be expanded for each section as needed. DO NOT DELETE ANY
MATERIAL FROM ORIGINAL HEALTH HISTORY FRAMEWORK.
The health history of your client—age 50 and older—must reflect an indepth interview. Under the Review of System—expand each illness described—also answer the questions asked, especially under Health Promotion. Do not write any physical examination findings in health history. This is a legal document—confidentiality is expected—do not use client name, only initials; no address or phone numbers. No white-out, cross-out marks will be accepted on formal document.
Each section must have complete data. Under Review of System: you need to read each bodily section, as each area asks about different habits and diseases. For example—under Head--if there is no history of problems—type DENIES ANY. If there is a problem identify—describe it, then type DENIES OTHERS. DO NOT USE “NO or NONE NOTED”responses.
2. For Genogram—use a separate piece of paper to draw out and label. You need to have a key explaining diagram and a reference source. You need to include—ages, sex, health status.
For Credit, three generations are required for GENOGRAM. Ask your clients for details before beginning health history interview, as you may need to select another client who can fulfill requirements.
5. Under SOAPER, for interventions, document reference source using APA format.
Attach SOAPER PROBLEM LIST (Located on following page in syllabus) to
COMPLETED HEALTH HISTORY
***Put all documents together Health History, Genogram and SOAPER
Grading for the Health History, Genogram and SOAPER Problem List --emphasis is on an accurate, logical and complete recording of health history, problem list, with nursing diagnoses, nursing interventions (references cited APA format), evaluation and response.