Religious, Cultural, Spiritual Beliefs, History Taking, Physical Exam, & Documentation Strategies

August 21, 2023August 21, 2023 Discipline: Nursing

Module 1 – Discussion

 

Religious, Cultural, Spiritual Beliefs, History Taking, Physical Exam, & Documentation Strategies 

 

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number. 

 

 

Case 1

 

·       76-year-old Black/African-American male with disabilities living in an urban setting.

·       Adolescent Hispanic/Latino boy living in a middle-class suburb

 

Once you received your case number, answer the following questions:

1.    What are the barriers to interpersonal communication?

2.    What are the procedures and examination techniques that will be used during the physical exam of your patient?

3.    Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.

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