health history Flashcards
one of the main purposes of collecting health history (Exam)
collecting subjective data to combine with objective data from the physical exam and lab studies to for the database (baseline for the patient)
purpose of health history
- Provides a complete picture of patient’s past and present health status
- Screening tool for detection of abnormalities
- Printed or electronic format that is available for review, validation, and updates
- Sequence may vary in terms of obtained information.
- Focus may differ in terms of clinical practice setting and/ or nature of complaint.
the health history sequence
- Biographic data
- Reason for seeking care
- Present health or history of present illness
- Past medical history
- Medication Reconciliation
- Family history
- Review of systems
- Functional assessment including activities of daily living (ADLs)
the health history in an adult
Record date and time
○ Biographic data
○ Source of history
○ Reason for seeking care
○ Present health or history of present illness
○ Past health
○ Family history
○ Additional questions for special populations
what is biographic data
- Name, address, and phone number
- Age, birth date, and birthplace
- Gender & preferred pronoun, relationship status
- Race and ethnic origin
- Occupation: usual and present
- Primary language
○ Language-concordant provider or medical interpreter
what is the source of the history
- Record who furnishes information, usually the person,
although source may be relative or friend. - Judge reliability of informant and how willing they are to
communicate.
○ Reliability leads to consistency of information.
Note any special circumstances, such as use of
interpreter.
what is important about reliability in the source of health history (Exam)
reliability leads to the consistence of information
reasons for seeking care
● Brief spontaneous statement in individual’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
● Focus on patient’s prioritized reasons for seeking care.
what is important when documenting the reason for seeking care (exam)
document any reported findings
- in quotations
focus on the patients prioritized reasons for seeking care
present health or history or present illness (HPI)
Collect all provided data and identify eight critical characteristics
Make sure that collected data are precise and accurate.
○ Use measurable standards and/ or patient’s own words as qualifiers.
Use standardized indicators to document findings
○ Reliability and validity of reported results
the nine critical characteristics of HPI (Exam)
- Location—be specific and precise
- Character or quality—provide descriptive terms
- Quantity or 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?
- Patient’s perception—how does it affect you?
PQRSTU mnemonic
Organize question sequence to obtain all relevant data
○ P = Provocative or palliative
○ Q = Quality or quantity
○ R = Region or radiation
○ S = Severity scale: 1 to 10
○ T = Timing or onset
○ U = Understand patient’s perception of problem
past medical history
● Each of the identified areas can have residual impact on present (as well as future) health status.
● Focus on obtaining specific pertinent information relative to each of the identified categories
● Leads to better clinical decision making.
● Will provide cues as to how patients cope with illness and/ or health concerns
childhood illnesses
experienced or exposed to presence or absence of complications
- were you immunized or did you have something
accidents or injuries
type and nature of event, acute and/or residual deficit noted
serious or chronic illnesses
presence of comorbidities has pronounced effects
hospitalizations
types based on clinical indications, interventions used as therapy, and length of stay along with dates of occurences
operations
facility, name of health care provider, and date of procedures
immunizations
correlation with CDC guidelines
last examination date
obtain the last data set for commonly occurring labs/diagnostics
allergies
note any allergens and their reaction to it
current medications
- perform medication reconciliation
- include prescribed and OTC medications and/or herbal therapy
family history
● Highlights diseases or conditions that an individual may be at risk for as a result of genetics
● Provides age and health or cause of death of relatives
● Ability based on results to seek early screening, make possible lifestyle adjustments, and/ or undergo periodic surveillance
● Pedigree or genogram used as standardized tool to organize data
additional questions for immigrants
Ask about:
○ Biographic data: entered the country from where?
○ Spiritual resource and religion: assess if certain procedures cannot be done
○ Past health: what immunizations, if any
○ Health perception
■ How does person describe health and illness?
■ How does person see problems he or she is now experiencing?
○ Nutrition: taboo foods or food combinations
the purpose of Review of systems (ROS) (3rd on exam)
- 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
review of systems head to toe approach
● Head-to-toe approach
○ Organized manner proceeding in a logical sequence
● Items within different systems may not be inclusive
○ If information obtained in HP I, then it doesn’t have to be re-assessed again
using language to facilitate communication with review of systems
translate all medical terms
avoid writing negative for body systems as you want to record either the presence of absence of symptoms
review of systems what to include and not to include
Do not include objective data.
○ Limit to patient statements or subjective data.
● Include all relevant body systems.
○ Include pertinent document relevant to the individual patient.
○ Focus on health promotion for each identified area.
general overall state with system approach
General overall health state
● Skin, hair and nails
● Head
○ Eyes and ears
○ Nose and sinuses
○ Mouth and throat
○ Neck
○ Breast and axilla
focus on body systems in systems approach
focus on the body systems while looking at specific indicators and focusing on health promotion
- respiratory, cardiovascular, peripheral vascular, gastrointestinal, urinary, male and female genital system and sexual health, musculoskeletal, neurologic, hematologic, endocrine
what are functional assessments
● ADLs
○ Self-care activities of daily living as they relate to general health status
● Objectively measure functional status
○ Monitor and assess for changes over time.
● Relevant data r/ t lifestyle and type of living environment
○ May include “sensitive” topics r/ t lifestyle behaviors and as such may require attention to privacy concerns
what is really important to functional assessments (Exam)
ADLs -> these are self-care activities of daily living as they relate specifically to general health status
functional assessment of ADLs important parts
Self-esteem, self-concept
Activity/ exercise
Sleep/ rest
Nutrition/ elimination
Interpersonal relationships/ resources
Spiritual resources
Coping and stress management
Personal habits- tobacco, alcohol, marijuana
Illicit or street drugs
Environment/ hazards
Intimate partner violence
Occupational health
their own (the client’s own) perception of their health
Ask questions such as the following:
○ How do you define health?
○ How do you view your situation now?
○ What are your concerns?
○ What do you think will happen in the future?
○ What are your health goals?
○ What do you expect from your healthcare team?
