LM1 - health history Flashcards
why do we get a patient’s health history?
- determine risk factors
- establish baseline
- opportunity for health teaching
how do we collect a patient’s health history?
- collect and analyze data
- use standardized format
- establish comfortable interview style
what are the types of data we can collect?
subjective data
- symptoms
- primary source (patient) vs. secondary source (family)
objective data
- signs
how do we address barriers and adapt communication?
- establish rapport
- avoid medical jargon
- adapt your communication - ex. Martil
how do we set cultural safety?
- creating safe spaces
how do we adjust our communication style?
verbal
- eye contact
- nodding
- replying
nonverbal
- no eye contact
- hand gestures
- posture
what are the components of a health history?
- demographic and biological data
- reason for seeking healthcare
- current and past medical history
- family health history
- functional health and activities of daily living
- review of body systems
what is demographic and biological data?
- name
- contact info
- birthdate
- age
- gender/preferred pronouns
- allergies
- languages spoken
- relationship status
- occupation
- resuscitation status
what does reason for seeking health care mean?
the patient’s chief complaint
what does the current and past medical history contain?
- current health
- medications
- allergies
- childhood illnesses, chronic illnesses, acute illnesses and surgeries
- reproductive health
- immunizations
what does the family health history contain?
- any genetic disorders or conditions
what is a review of the body systems contain?
- focused questions related to the body systems
what are the functional health categories?
- nutritional-metabolic
- elimination
- activity-exercise
- sleep-rest
- cognitive-perceptual
- role-relationship
- sexuality-reproductive
- coping-stress tolerance
-value-belief - self-perception and self-concept
- health perception-health management
