Health History Flashcards
What is subjective data that you collect in a complete health history?
Subjective data in a Complete Health History is what the patient says about themselves. This includes;
Biographic Data
Reason for Seeking Care
Present Health/ History of Present Illness
Past History
Medication Reconciliation (comparing medications patient is taking to medication orders)
Family History
Review of Systems
Functional assessment of ADL
Perception of Health
What is the objective data in a complete health history? When is it usually performed?
Objective Data in a complete health history is the material that comes from the assessment and is typically done after complete health assessment, unless there is an emergent issue that requires immediate attention.
What is a Genogram? And what is its function?
A Genogram is a graphic family health history tree that includes the conditions and diseases of each person. Ideally it will include 3 generations of family if possible.
This family history tree will attempt to highlight areas of increase risk for a patient.
What is PQRSTU?
Palpability/ Provacative factors
Qauntitative or how it feels (hard, stabbing, ect.)
Region or where is it occuring?
Severity of pain on a scale of 0-10
Timing or when symptoms tend to occur
Understanding, specifically what the patient understands to be happening to them or what they think it is.
What makes up biographical data in a complete health history? And what is important to note upon obtaining this information?
Biographical data includes;
Name, address, phone #, age, birthdate, birthplace, gender, relationship status, ethnic origin, and occupation and primary language. This information is often obtained prior to the appt. through patient paperwork.
However it is important to know the reliability and source of this data. (Is the patient themselves telling you this or is someone else telling you?)
When noting a objective datas source and reliability describe some key factors that you should consider?
You want to take a look at the informations source and consider;
Who is furnishing the infor? (is it the patient or interpeter (More reliable) , a friend, family? (Less reliable))
How willing is the informant to give information? Is is consistent? (i.e. reliable persons answers are the same even if questions are repeated or rephrased later).
How is the persons health? (i.e. a sick patient might comuunicate poorly).
