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The University of Southampton

NQCG3127 Foundations in History Taking and Physical Assessment

Module Overview

Aims and Objectives

Module Aims

To equip you with a) Enhanced knowledge, skill and critical awareness in relation to patient/client history taking and recording, and the ability to differentiate normal vs abnormal findings. b) A foundation level of skills and critical awareness in relation to the systematic physical assessment of patients/clients across the lifespan, and the ability to differentiate normal vs abnormal findings. This will be underpinned by a enhanced knowledge base in relation to relevant/applied anatomy and physiology.

Learning Outcomes

Learning Outcomes

Having successfully completed this module you will be able to:

  • Demonstrate knowledge, skill and understanding in patient/client consultation, including data gathering, data processing and communication, and be able to critically appraise the place of these skills and underpinning knowledge within the context of a holistic health assessment.
  • Demonstrate knowledge, skill and understanding in physical assessment across major body systems, and appraise the application of these skills and their underpinning knowledge in the context of care delivery across the lifespan.
  • Critically consider the contribution of assessment tools and early warning scoring systems in the effective assessment of physiological deterioration or 'red flags' indicative of the need for emergency or urgent intervention.
  • Distinguish and explain findings of ‘normality’ and ‘deviations from normality’ in the assessment process, including those influenced by genetic, ethnic, physiologic, anatomic and developmental/lifespan differences, and demonstrate the ability to seek advice and/or make credible referrals as appropriate.
  • Demonstrate self awareness regarding the importance of maintaining respect for privacy, dignity and confidentiality when undertaking health assessment.
  • Articulate the contribution of the evidence base underpinning the implementation of history taking and physical assessment skills within the context of professional practice.
  • Critically consider the interface between knowledge and skills of patient/client assessment gained during pre-registration training, and the use of these enhanced history taking and physical assessment skills in the context of expanded/extended practice.


Syllabus content for this module is underpinned by extensive insights and feedback that have been gained during the 12 years over which this programme has been run at academic levels 5, 6 and 7. It has also been informed by the considerable experience of the team which delivers the programme, which includes consultant practitioners, lecturer/practitioners and seconded practitioners alongside academic staff. The level 6 module lead is currently undertaking her doctoral studies exploring how history taking and physical assessment skills are used in practice within an acute care environment. The level 7 module lead, who contributes significantly to the level 6 module has extensive experience of undertaking research in the field of advanced health assessment and advanced clinical practice, with her doctorate studies centred on the utilisation of these skills by nurses in the context of paediatric pre-operative assessment. A subsequent scholarship/study tour enabled her to explore how these skills are taught and assessed across a number of centres in the UK, Republic of Ireland, Canada and the United States. Extensive literature searching has further underpinned programme development, and use of core texts from both the US and UK (texts widely used across the UK and many other countries world) ensures national and international transferability of the skills taught. A textbook adapted for UK use by the level 7 module lead is also a core text for the programme. Extensive consultation with purchasers and former students has also very helpfully informed the development of this most recent iteration of the module, with an extremely strong advocacy that in large part the content and format of the 2007 module be retained. The syllabus content is as follows: • Methods of undertaking a systematic, comprehensive health history across all major body systems, using a range of different assessment tools and formats. Includes mental health screening. • Relevant anatomy and physiology, particularly ‘surface anatomy’, pertaining to all major body systems, including variations across the lifespan, and variations occurring as a result of gender or ethnicity. • The role of the ‘general survey’; including inspection of hands, nails, hair, skin and face as a core assessment process which underpins and integrates the physical examination. • Utilisation of the physical examination skills of inspection, palpation, percussion and auscultation across all major body systems (including respiratory, cardiac, gastro-intestinal, genitor-urinary, neurological and musculo-skeletal systems, as well as inspection of eyes, ears, nose and throat) • The challenges of integration: respiratory and cardiovascular assessments, and neurological and musculoskeletal assessment. • Interpretation of assessment findings to enable the distinction between ‘normal’ and ‘abnormal’ findings, including variations of normality. • Making credible referrals in cases of proven or suspected abnormality. • Documentation of findings from all history taking and physical assessment processes • Contextualising of history taking and physical examination skills by critical analysis of different models and frameworks of health assessment, including assessment tools and early warning scoring systems that are used to elicit evidence of patient deterioration or 'red flags' requiring urgent or emergency intervention. • Exploration of the assessment skills learned during pre-registration training, and how these interface with the new expanded skills in history taking and physical assessment that form the basis of this programme. • Exploration of legal, professional and ethical issues pertaining to the changing/blurring of role boundaries between and within different health care professions. • Critical consideration of the evidence base underpinning health assessment and role extension/ expansion. • Consideration of issues relating to privacy, dignity and confidentiality in the context of health assessment.

Special Features

This module is designed to meet the assessment skills required as a pre-requisite for those undertaking a non-medical prescribing programme at level 6. We have found it particularly useful to give course members information about the skills practice component of the course. This is both to allay concerns about what may be involved, and to give you time in advance of the course to reflect on whether the way it is delivered is acceptable to you. In order to learn and practice the skills taught on this module the class is divided into small groups consisting of a minimum of two to a maximum of six persons (normally between three and five per group). Small groups may comprise both male and female members and as far as is feasible, each small group will have an instructor/facilitator, who may be male or female. In these small groups you will have the opportunity to practise different assessment skills on each other. Participation in the ‘patient role’ is not compulsory, and if you have individual concerns you are invited to discuss these with the module leader. However, undertaking the patient role does add considerably to the learning experience and you will be asked on day one of the module to sign a form giving your consent to participate in the module in this way. Guidance re appropriate clothing (e.g. sportswear/crop tops/shorts) will be given for each body system but underwear is never removed. Every effort is made to ensure privacy and dignity and screens/curtains are used to screen doors and/or bed spaces as appropriate/feasible depending on location to help ensure preserve. Course and cohort leaders ensure every effort is made to create a learning environment that is non-threatening, safe and enjoyable to work in for all concerned. Ground rules are agreed on the first day. Please take time to reflect on the above. If you have concerns about whether the above is acceptable, feel free to contact the module leader or deputy module leader.

Learning and Teaching

Teaching and learning methods

The course uses a wide variety of teaching and learning methods. The emphasis is very much on the importance of self directed learning, accompanied by a considerable emphasis on skills rehearsal. Atypically, you are encouraged to identify a core text as the basis of your learning, and to supplement this by accessing other texts, relevant journal publications and on line resources. You are also encouraged to explore the evidence base underpinning the utilisation of these skills. Learning is also supported by your access to the on line blackboard learning environment, which includes core and supporting learning materials, and video demonstrations of the skills being taught. You are strongly encouraged to read relevant hand outs and book chapters before each session, and to revisit these materials after each session, to maximise effective learning and consolidation. You are also strongly encouraged to identify mechanisms by which you can practice the skills taught, both within your professional working environment and informally. Much of the study time allocated to the programme needs to be used for skills rehearsal to ensure effective learning and execution of the skills taught. Some of this will take place within your working environment, but this will need to be supplemented by informal practice. Importantly, although skills and knowledge are examined at the end of the programme, and a required standard must be reached, successful completion of the course does not confer confirmation of competence. Rather, it is acknowledged that competence is context specific, and also normally takes considerably longer to achieve than the total length of the programme. You are therefore given guidance regarding how competency can be achieved within your own practice setting after the course is completed. A wide range of teaching and learning methods will be used, and are likely to include: • Lectures • Demonstrations • Supervised skills practice on peers • Audio-visual presentations • Quizzes • Self directed learning (including books, journals, audio-visual resources etc.) • E-learning (including use of Blackboard and other on-line resources.) • Supervised skills rehearsal within the practice setting. (The module is not formally assessed in practice but you are encouraged to develop informal arrangements to enable you to undertake supervised skills rehearsal/development within your particular clinical practice domain.)

Independent Study150
Total study time200

Resources & Reading list

You will need to have access to a copy of at least one of these core texts, or an equivalent text, for the duration of the course.. 

Lumley,J (2008). Surface Anatomy: The Anatomical Basis of Clinical Examination. 

Seidel,H., Ball,J., Dains,J.,Flynn,J, Solomon,B, Stewart,R. (2010). Mosby’s Guide to Physical Examination. 

Hogan-Quigley,B; Palm,M and Bickley,L (2011). Bates Nursing Guide to Physical Examination and History Taking. 

Jevon,P (2009). Clinical Examination Skills. 

Epstein,O., Perkin G., Cookson, J., & Watt, I. (2008). Clinical Examination. 

Rawles,Z., Griffiths,B. and Alexander,T. (2010). Physical Examination Procedures for Advanced Nurses and Independent Prescribers. 

Fergusson,D. (2008). Clinical Assessment and Monitoring in Children. 

Jarvis, C., (2011). Physical Examination and Health Assessment. 

Marieb, E. and Hoehn,K (2012). Human Anatomy and Physiology. 

Rushforth, H (2009). (UK adapter) Assessment Made Incredibly Easy. 

Tortora,G. and Derrickson,B. (2011). Principles of Anatomy and Physiology. 

Bickley, L. S., Szilaygi,P.G., (2009). Bates’ Guide to Physical Examination and History Taking. 



Field/laboratory/practical exercises


MethodPercentage contribution
Objective Structured Clinical Examination  (2 hours) 100%


MethodPercentage contribution
Objective Structured Clinical Examination 100%

Repeat Information

Repeat type: External

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