History Taking: Mam Daniela

Question 1

Types of Health Histories

Answer 1

1. Complete health history

2. focused health history

Question 2

PQRST

Answer 2

Precipitating/Palliative Factors
Quality/Quantity
Region/Radiation/Related Symptoms
Severity
Timing

Question 3

The ________ provides the subjective database for your assessment. Often, it is your first major interaction with your patient so make it count. You have only one chance to make a good first impression, and it is often the first impression that your patient will remember.

Answer 3

Health History

Question 4

The ________ provides clues to genetically linked or familial diseases that may be risk factors for your patient.

Answer 4

Family History

Question 5

The _________ provide you with direct information related to a current health problem, alert you to risk factors for health problems, and point out the need for referrals.

Answer 5

Biographical Data

Question 6

The ______ assesses childhood illnesses, hospitalizations, surgeries, serious injuries, adult medical problems (including serious or chronic illnesses), immunizations, allergies, medications, recent travel, and military service.

Answer 6

Past Health History

Question 7

The _______ is a litany of questions specific to each body system.

Answer 7

Review of Systems (ROS)

Question 8

The _________ gives you a picture of your patient’s health promotion and preventive patterns. It includes a description of health practices and health beliefs, a typical day, nutritional patterns, activity/exercise patterns, etc.

Answer 8

Psychosocial Profile

Question 9

The ________ enables you to identify how your patient incorporates health practices into every aspect of her or his life.

Answer 9

Psychosocial Assessment

Question 10

The purpose of the health history is to:

Answer 10

o	Provide the subjective database.
o	Identify patient strengths.
o	Identify patient health problems, both actual and potential.
o	Identify supports.
o	Identify teaching needs.
o	Identify discharge needs.
o	Identify referral needs.

Question 11

what are the helpful hints for documenting a health history regardless of the system?

Answer 11

o Be accurate and objective. Avoid stating opinions that might bias the reader.
o Do not write in complete sentences. Be brief and to the point.
o Use standard medical abbreviations.
o Don’t use the word “normal.” It leaves too much room for interpretation.
o record pertinent negatives. Be sure to date and sign your documentation.