Ch. 4- The Complete Health History Flashcards
What is the Health History Sequence?
- Biographical data
- Source of history
- Reason for seeking care or chief concern
- Present health or history of present illness
- Past health
- Social history
- Family history
- Review of symptoms (ROS)
What are biographical data-demographics?
- Name, address, phone
- Age and DOB
- Birthplace
- Gender
- Relationship status
- Race
- Ethnic origin
- Occupation
- Primary Language
- Insurance
- Advanced directives
Who is a reliable source of history?
A reliable person gives same answers when questions are rephrased or are repeated later in interview.
(Note any special circumstances, ex: interpreter)
What does the reason for seeking care/CC look like?
- Brief spontaneous statement in person’s own words describing reason for visit. (Enclosed in quotations)
- CC is no longer preferred language
How should you evaluate the history of present illness? (HPI)
- OLDCARTS
- Onset
- Location
- Duration
- Characteristics
- Aggravating and alleviating factors
- Related symptoms
- Treatments tried
- Severity- use pain scale
Why do we use OLDCARTS or PQRST?
It is a methodical way that collects more information.
What things should be included in a persons past medical history?
- Childhood illness
- Accidents or injuries
- Serious or chronic illnesses
- Hospitalizations
- Surgeries
What things would you include when documenting an obstetrics history?
- # of pregnancies: gravity (G)
- # of deliveries in which fetus reached full-term: Term (T), sometimes written as para (P)
- # of preterm pregnancies: preterm
- # of incomplete pregnancies due to miscarriage or abortion: abortion (Ab)
- # of living children: Living (L)
- Labor and delivery course: Normal spontaneous vaginal delivery (NSVD)
- Pregnancy complications
What things would you record in a persons social history?
- Tobacco
- Alcohol
- Illicit drug use
- Sexual history
- Intimate partner violence
- Social determinants of health
- Etc: exercise, sleep, diet, …
What things would be recorded in a persons family history?
- Diseases or conditions an individual may be at risk for
- Age and health cause of family members deaths
- Ability based on results to seek early screening, make possible lifestyle adjustments, and/or undergo periodic surveillance
What is used as a standardized tool to organize a individuals family history?
Genogram or pedigree.
Explain what ROS is?
- Summary of subjective data
- Comprehensive review of each body system
What is the ROS used to identify?
Any other potential problems or concerns not previously covered.
What does the ROS aide in?
Health promotion.
What things are included in the ROS?
All assessments we do.
