Why is accurate and complete documentation in the electronic health record important to reimbursement and quality of care?
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- Health Screening and History of an Adolescent or Young Adult Client. Project description Assignment Health Screening and History of an Adolescent or Young Adult Client (A Direct Care Experience) View Rubric Due Date: Nov 17, 2013 23:59:59 Max Points: 150 Details: In this assignment, you will be completing a comprehensive health screening and history on a young adult. To complete this assignment, do the following: Select an adolescent or young adult client on whom to perform a health screening and history. Students who do not work in an acute setting may “practice” these skills with a patient, community member, neighbor, friend, colleague, or loved one. Complete the “Health History and Screening of an Adolescent or Young Adult Client” worksheet. Format the write-up in a manner that is easily read, computer-generated, neat, and without spelling errors. Complete the assignment as outlined on the worksheet, including: 1. Biographical Data 2. Past Health History 3. Family History: Obstetrics History (if applicable) and Well Young Adult Behavioral Health History Screening 4. Review of Systems 5. Include all components of the health history 6. Use correct acronyms or abbreviations when indicated 7. Develop three Nursing Diagnoses for this client based on the health history and screening. Include: one actual nursing diagnosis, one wellness nursing diagnosis, one “Risk For” nursing diagnosis, and your rationale for the choice of each nursing diagnosis for this client. While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment.
- Effective Documentation and Electronic Medical Record
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