Health Histroy And Documentation Flashcards
Purpose of health history
-subjective data
-trusting and supportive relationship while still gathering information
-past and current health
-screening tool for abnormalities
Components of health history
-biographical data
-reason for seeking health care
-current/history of health
-family histroy
-review of systems
-functional assessment and actives of daily living
What is the primary source of information?
Patient him/herself
Primary vs secondary sources of data
Patient - patient
Secondary - all other sources
Reliability of source
The trust in the answers
-may need to rephrase and ask same questions to see the similarity in responses
What is a better question to ask besides “why”
What’s been going on?
What makes up a statement indicating patients reason for seeking care?
Coming in with a symptom, usually is a quote in their ow words
Health history helps you
Begin to identify the patients health strengths and problems, and contextual influences
The interview
-first
-collection of subjective data
Unconditional positive regard
Generally optimistic view of people
-assumption of their strengths
-acceptance of limitations
How far apart should you be from a patient and why
1.5m (twice arms length)
-may invade privacy any closer, and further may be distant seeming
Where should the patient be situated in the room
The patient should be sitting so their back is not facing the door
-this may make them feel blocked in
Ten traps of interviewing
F,A,A,A,D,P,B,T,I,W,
