DATA Flashcards
Client’s name, address, age, sex, marital status, occupation, religious preference, health care financing, and usual source of medical care.
Biographic data
The answer given to the question “What is troubling you?” or “Describe the reason you came to the hospital or clinic today.”
Chief complaint or reason for visit
HISTORY OF PRESENT ILLNESS
• When the symptoms started
• Whether the onset of symptoms was sudden or gradual
• How often the problem occurs
• Exact location of the distress
• Character of the complaint (e.g., intensity of pain or quality of sputum, emesis, or discharge)
• Activity in which the client was involved when the problem occurred
• Phenomena or symptoms associated with the chief complaint
• Factors that aggravate or alleviate the problem
• Illnesses, such as chickenpox, mumps, measles, rubella (German measles), rubeola (red measles), streptococcal infections, scarlet fever, rheumatic fever, hepatitis, polio, and other significant illnesses
• Immunizations and the date of the last tetanus shot
• Allergies to drugs, animals, insects, or other environmental agents, the type of reaction that occurs, and how the reaction is treated
• Accidents and injuries: how, when, and where the incident occurred, type of injury, treatment received, and any complications
• Hospitalization for serious illnesses: reasons for the hospitalization, dates, surgery performed, course of recovery, and any complications
Past history
all currently used prescription, over-the-counter medications, such as aspirin, nasal spray, vitamins, or laxatives, and herbal supplements
Medication
To ascertain risk factors for certain diseases, the ages of siblings, parents, and grandparents and their current state of health or, if they are deceased, the cause of death are obtained.
Family history of illness
Particular attention should be given to disorders such as heart disease, cancer, diabetes, hypertension, obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism, and any mental health disorders.
Family history of illness
LIFESTYLE :
-PH
-D
-SP
-ADL
-IA
-R or H
-Personal habits
-Diet
-Sleep pattern
-Activities of daily living (ADLs)
-Instrumental ADLs
-Recreation or hobbies
the amount, frequency, and duration of substance use (tobacco, alcohol, coffee, cola, tea, and illegal or recreational drugs)
Personal habits
description of a typical diet on a normal day or any special diet, number of meals and snacks per day, who cooks and shops for food, ethnic food patterns, and allergies
Diet
usual daily sleep/wake times, difliculties sleeping, and remedies used for difficulties
Sleep patterns
any difficulties experienced in the basic activities of eating, grooming, dressing, elimination, and locomotion
activities of daily living (ADLs)
any difficulties experienced in food preparation, shopping, transportation, housekeeping, laundry, and ability to use the telephone, handle finances, and manage medications
instrumental ADLs
exercise activity and tolerance, hobbles and other interests, and vacations
recreation or hobbies
• Major stressors experienced and the client’s perception of them
• Usual coping pattern for a serious problem or a high level of stress
Psychological data
• Communication style: ability to verbalize appropriate emotion; nonverbal communication-
psychological data
All health care resources the client is currently using and has used in the past.
These include the primary care provider, specialists (e.g., ophthalmologist or gynecologist), dentist, folk practitioners (e.g., herbalist or curandero), health clinic, or health center; whether the client considers the care being provided adequate; and whether access to health care is a problem.
Patterns of healthcare
SOCIAL DATA
-Family relationship or friend
-Ethnic affiliation
-Educational history
-Occupation history
-Economic status
-Home and neighborhood conditions
the client’s support system in times of stress (who helps in time of need?), what effect the client’s illness has on the farily, and whether any family problems are affecting the client
Family relationships/friendship
heath customs and beliefs; cultural practices that may affect health care and recovery
Ethnic affiliation
data about the client’s highest level of eduation attained and any past dificulties with learning
Educational history
current employment status, the number of days missed from work because of iliness, any history of accidents on the job, any occupational hazards with a potential for future disease or accident, the client’s need to change jobs because of past illness, the employmont status of spouses or partners and the way child care is handled, and the client’s overall satisfaction with the work
Occupational history
information about how the client is paying for medical care (including what kind of medical and hospitalization coverage the client has) and whether the client’s illness presents financial concerns
Economic status
home safety measures and adjustments in physical facilitles that may be required to help the client manage a physical disability, activity intolerance, and activities of dally living; the availability of neighborhood and community services to meet the client’s neods.
Home and Neighbourhood condition
