History Flashcards
History Categories
Demographics Current Conditions/Chief Complaints Pt Goals Prior Level of Function Social Hx Employment Status Living Environment General Health Status Social/Health Habits Family Health Hx Pt's Medical/Surgical Hx Functional Status/Activity Level Medications Growth & Development Other Clinical Tests
Demographic
Identifying Information:
name, address, admission date, DOB, sex, dominant hand, race, ethnicity, language, education level, ADP, referral source/reason
Current Conditions/Chief Complaints
Date of onset, incident of onset, how pt caring for problem
Other practitioner pt seeing for problem
Pt Goals
pt and sometimes family goals for therapy as told to therapist by pt or family/caretaker
Prior Level of Function
pt’s level of function prior to most recent onset of current condition/complaints
Social Hx
cultural & religious beliefs that might affect care
person(s) pt lived with prior to admission/will leave w/ after discharge
Available social/physical supports
Employment Status
Full-time or Part-time
Inside vs. outside home
Living Environment
Assistive devices/equipment pt uses
Stairs/ramps available, past use of community services
General Health Status
Pt’s rating of his or her health and whether pt has experienced any major life changes in past year
Social/Health Habits
Alcohol/tobacco use & exercise habits
Family Health Hx
conditions that family members have had
Pt’s Medical/Surfical History
Past admissions & procedures
Functional Status/Activity Level
Bed mobility, transfers, gait, self-care, home management, community & work activities that apply to pt’s current situation/condition
Medications
List of everything they are currently taking & known allergies
Growth & Development
Primarily for pediatrics, development history
