Health History Flashcards
Refers to a series of information used to provide an overview of the current health status of the patient
Health History
May either be a _____health history or _____ health history
comprehensive
problem-oriented
HEALTH HISTORY
* Refers to a __________ used to provide an _____ of the current __________ of the patient
series of information
overview
health status
SOURCES OF DATA
Patient
Family Members and Significant Others
Authorities
Patient’s old medical records
Total Strangers
METHODS OF GATHERING DATA
Interview
Record Review
Preparing for the Interview
Self reflection
Reviewing the patient’s records
Setting goals for the interview
Preparing for the venue
Structure of an Interview (GOEECNP)
- Greeting the patient
- Obtaining the chief complaint
- Establishing goals for the interview
- Expanding and clarifying the patient’s chief complaint
- Creating a shared understanding of the problem
- Negotiating a plan
- Planning for follow-up and terminating the interview
- Greeting the patient
o Establish rapport
o Greet the patient by name and introduce self as appropriate - Obtaining the ______
o Begin with ______
o Avoid interrupting the patient as he/she talks at this point - Establishing ______
o Together with the patient, identify all pressing issues or slapped Focus the interview by asking the patient which problem is most pressing - Expanding and clarifying the patient’s chief complaint o Clarify the attributes of the patient’s chief complaint including context, association and chronology
- Creating a ______
- It is important for the nurse to o It is important for the nurse to ______ about the present illness or health problem
- Negotiating a_____
- Planning for _____and _____ the interview
chief complaint
open-ended questions
goals for the interview
shared understanding of the problem
explore the patient’s perspective
shared understanding of the problem
plan
follow-up & terminating
Effective Interview Techniques (AANFEEVRSH)
Active Listening
Adaptive Questioning
Nonverbal Communication
Facilitation
Echoing
Empathic responses
Validation
Reassurance
Summarization
Highlighting transitions
TYPES OF HEALTH HISTORY
Episodic Health History
Interval or Follow-up Heath History
Emergency Health History
Complete or Comprehensive Health History
COMPONENTS OF THE HEALTH HISTORY
- Biographical Data
- Chief Complaint
- Present Health History
- Past Health History
- Family History
- Review of Systems
- Patient Profile
Qualifiers of a Chief Complaint
Location
Radiation
Quality
Quantity
Associated Manifestations
Aggravating Factors
Alleviating Factors
Setting
Timing
Meaning and Impact
Used to identify disease that may be genetic, communicable or environmental in origin
* A family genogram may be used to facilitate data gathering and recording
Family health history
Includes an overview of general health as well as symptoms related to each body system
* May be done in conjunction with the physical assessment
Family history
PQRST mnemonic
Provoke the pain
Quality
Region and location
Severity and setting
Timing
Component of health history
Biographical data
Chief complaint
Present health history
Past health history
Family health history
Review of systems
Lifestyle and health practices
Past health history
Immunization status
Childhood illness
Adult illmess
Psychiatric illness
Allergies
Hospitalization
Present hereditary and familial disease
Genogram
Qualifiers of a Chief Complaint
Location
Radiation
Quality
Quantity
Associated manifestation
Aggravating Factors
Alleviating Factors
Setting
Timing
Meaning and Impact
