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Health Assessment Exam 1 > Chapter 4 - The Complete Health History > Flashcards

Chapter 4 - The Complete Health History Flashcards

1
Q

What is the Health History Sequence?

A
  • 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 systems (ROS)
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2
Q

What are Biographical Data-Demograhics?

A
  • Name, Address, phone
  • Age & birth date
  • Birthplace
  • Gender
  • Relationship status
  • Race
  • Ethnic origin
  • Occupation
  • Primary Language
  • Insurance
  • Advanced Directives
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3
Q

Reliability?

A

A reliable person always gives same answer when questions are rephrased or are repeated later in the interview

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4
Q

What should you take into account in regards to the Source of History?

A
  • Who furnishes information
  • Reliability
  • Note any special circumstances, such as use of an interpreter
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5
Q

What is a Chief Complaint or Chief Concern?

A

A brief spontaneous statement in a person’s own words describing the reason for the visit

  • Typically written in quotes “ “
    - to indicate person’s exact words
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6
Q

Chief complaint is no longer what?

A

No longer the preferred language

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7
Q

OLD CARTS is used in what part of the complete health history?

A

History of Present Illness (HPI)

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8
Q

OLD CARTS stands for what?

A 
Onset
Location
Duration
Characteristics
Aggravating & Alleviating factors
Related symptoms
Treatments tried
Severity (use a pain scale)
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9
Q

In terms of Allergies, what components are needed for data collection?

A
  • Severity
  • Type of reaction
  • etc…
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10
Q

what are examples of classes of allergies?

A
  • Drugs
  • Food
  • Environmental factors
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11
Q

What are the Five rights of medication administration?

A
  • Right person
  • Right drug
  • Right dose
  • Right time
  • Right route
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12
Q

What questions should you ask regarding Past Medical History?

A
  • Childhood illnesses
  • Accidents or injuries
  • Serious or chronic illnesses
  • Hospitalizations
  • Surgeries
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13
Q

In terms of Past Medical History, what additional questions should you ask about Surgeries?

A
  • Facility
  • Name of health care provider
  • Date of procedures
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14
Q

In terms of Past Medical History, What additional questions should you ask about Hospitalizations?

A
  • Types based on clinical indications
  • Interventions used as therapy
  • Length of stay
  • Dates of occurrences
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15
Q

In terms of Past Medical History, What additional questions should you ask about Serious or Chronic Illnesses

A
  • Presence of comorbidities
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16
Q

In terms of Past Medical History, what additional questions should you ask about Accidents or Injuries?

A
  • Type & nature of event

- Acute and/or residual deficit noted

Health Assessment Exam 1 (2 decks)

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