Health History Flashcards
Health history includes: (8)
- biographic data
- source of history
- reason for seeking care
- present health/history of present illness
- past health
- family history
- review of systems
- functional assessment
brief spontaneous statement in person’s own words describing reason for visit
reason for seeking care
reason for seeking care findings should include: (2)
signs and symptoms
subjective sensation person feels from disorder documented in quotes
symptoms
objective abnormality that can be detected on physical examination or in laboratory reports
signs
T/F: reason for care is a diagnostic statement
false
Focus on patient’s _______ reason for seeking care
prioritized
2 focuses of history of present illness
- collect all provided data
- identify critical characteristics
data collected in history of present illness: (8)
- location
- character/quality
- quantity/severity
- timing
- setting
- aggravating/relieving factors
- associated factors
- patients perception
Use _____ _______ to document findings
standardized indicators
purpose of system reviews (3)
- 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
____________ approach: organized manner proceeding in a logical sequence
cephalocaudal
If information of review of systems is in the HPI:
it does not need to be re-assessed again
Review of systems approach: (5)
- general overall health state
- skin and hair
- head
- body systems looking at specific indicators focusing on health promotion
- systems specific to gender
Review of systems of head includes: (5)
- ears and eyes
- nose and sinuses
- mouth and throat
- neck
- breast and axilla
