Chapter 4: Complete Health History Flashcards
purpose of health history
-Collect subjective data to combine with objective data from physical exam and lab studies to form the database
-Provides a complete picture of patient’s past and present health status
-Can be used as a screening tool for detection of abnormalities
subjective vs objective data
-symptoms are subjective data (what the patient tells us)
-signs are objective data (what the nurse can see)
symptom vs signs
-symptom is something an individual experiences
-sign is something a doctor, or other person, notices
health history sequence
Biographic data
Source of history
Reason for seeking care
Present health or history of present illness
Past health
Family history
Review of systems
Functional assessment including activities of daily living (ADLs)
biographic data
Name, address, and phone number
Age, birth date, and birthplace
Gender (identification) and relationship status
Race and ethnic origin
Occupation: usual and present
Primary language
Try to find a Language concordant provider or medical interpreter
source of history
-Record who furnishes information, usually the person, although source may be relative or friend.
-Judge reliability of informant and how willing he or she is to communicate.
-Reliability leads to consistency of information.
-Note any special circumstances, such as use of interpreter
reason for seeking care
-Brief spontaneous statement in person’s own words describing reason for visit
-Document reported findings:
-Symptom: subjective sensation person feels from disorder documented in quotes
-Sign: objective abnormality that can be detected on physical examination or in laboratory reports
-Reason for care is NOT a diagnostic statement: Similar to Chief Complaint (CC)
-Focus on patient’s prioritized reasons for seeking
present health or history of present illness (HPI)
-Collect all provided data and identify eight critical characteristics
-Location, character(quality), quantity(severity), timing, setting, aggravating or relieving factors, associated factors and patient’s perception
what are the 8 critical characteristics
- Location: be specific and precise
- Character (Quality): provide descriptive terms
- Quantity (Severity): use scales to identify Intensity
- Timing: Onset, Duration, and Frequency
- Setting: Location and/or associated activity
- Aggravating or relieving factors: What makes it worse or better
- Associated factors: Is the concern r/t any other symptom? e.g. SOB (shortness of breath)
- Patient’s perception—how does it affect you
PQRSTU
P = Provocative or palliative
Q = Quality or quantity
R = Region or radiation
S = Severity scale: 1 to 10
T = Timing: onset, duration, frequency
U = Understand patient’s perception
past medical history and examples
-Each of the identified areas can have residual impact on present (as well as future) health status
-childhood illnesses, accidents/injuries, serious/chronic illnesses, hospitalizations, operations, pregnancy/obstetric history, immunizations, last examination date, allergies, current medications
family history
-Highlights diseases or conditions that an individual may be at risk for as a result of genetics
-Ability based on results to seek early screening, make possible lifestyle adjustments, and/or undergo periodic surveillance
purpose of reviews of systems (ROS)
-Evaluate past and present state of each body system
-Assess that all pertinent data relative to each body system have been noted
-Evaluate health promotion practices
-cephalocaudal approach (head to toe)
avoid writing what for ROS
Avoid writing “negative” for body systems. Instead write either “presence” or “absence” of symptoms
systems approach includes:
-general overall health state
-skin and hair
-head
-eyes
-ears
-nose and sinuses
-mouth and throat
-neck
-breast and axilla
-respiratory: Hx of lung disease
-cardiovascular: chest pain
-peripheral vascular: coldness, numbness, tingling
-gastrointestinal: appetite, food intolerance, dysphagia (difficulty swallowing)
-urinary: frequency, urgency
-musculoskeletal: Hx of arthritis
-neurological: Hx of seizure
-hematologic: excessive bruising
-endocrine: Hx of diabetes
-genital
-sexual health
