History Taking Flashcards
what is the purpose of history taking?
collect subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment
this type of assessment gathers a full history of the patient’s health status and current problems, as well as provides health promotion and risk reduction education.
initial comprehensive assessment
this type of assessment is a follow-up or update.
ongoing or partial assessment
this type of assessment assesses a particular problem.
focused or problem-oriented assessment
this type of assessment focuses on an emergent problem with a systematic prioritization.
emergency assessment
what the person tells you about themselves
subjective data
what you observe or measure
objective data
what are the steps of health assessment?
- collection of subjective data. 2. collection of objective data. 3. validation of data with physical exam. 4. documentation of findings.
what type of atmosphere do you want to create with a patient?
accepting, non-judgmental, empowering, supportive, understanding
what are some ways nonverbal communication is displayed?
appearance, demeanor, facial expression, posture, attitude, silence, listening, touch
what are some ways to make your patient comfortable with the EHR?
integrate typing around your patient’s needs, tell your patient what you are doing, encourage participation, and look at your patient
“why are you here?”
open-ended question
“are you in pain?”
close-ended question
“are you telling me that..?”
rephrasing
sequence of assessment
biographical data, chief complaint, HPI, PMH, family history, social history, review of systems, functional assessment
what are the seven dimensions of a symptoms?
location, quality, quantitative aspects, chronology, setting, aggravating and alleviating factors, related symptoms.
why are assessments important?
facilitate communication, provide database for all providers, easy retrieval of information
brief description of perceived problem in patient’s own words
chief complaint
chronological course of events using the 7 dimensions symptoms analysis
HPI
childhood/current illnesses, immunizations, surgery, hospitalizations, serious injuries, current meds, allergies, transfusions, obstetric history, last exams
PMH
age of parents and diseases, may include genogram
family history
smoking, drugs, alcohol, who you live with, occupation, exercise, sleep, stress management, nutrition
social history
organ system review, includes health promotion
review of systems
SOAP note includes:
subjective, objective, assessment, plan
objective data uses:
inspection, palpation, percussion, auscultation
