Module 1 Flashcards
Purpose of Health History
collect subjective data to combine with objective data from physical exam and lab studies to for the databasel provides a complete picture of pateints past and present health status; screening tool; focus may differ interms of clinical practice setting and/or nature of coplaint
Health history Sequence
biographic data, source of history, reason for seeking care, present health or history of present illnes, past health, family history, review of system, funcitionals assessment of ADLs
Biographic Data
name, address, and phone number; age, birth dat and birthplace; gender (identity as well) and relationship status; race and ethinic origin; occupation (past and present); primary language
Reason for Seeking Care
brief spontaneous statement in patients own words describing reason for visit; reason for care is not a diagnostic statement; focus on patients prioritzed reasons for seeking care
Symptom
subjective sensation person feels from disorder documented in quotes; such as pain, feeling nausuated, feeling dizzy
Sign
objective abnormality that can be deteced on physical examination or in a laboratory reports; vital signs, noticing sweat, notcing swaying
HIstory of Present Illness
collect all provided data and identify eight critical characterisitics; location, character, quantity, timiny, setting, aggravating/relieving factors, associated factors and patients perception;
Critical Characteristics of Present Illness
location ( be specific and precise); character or quality (provide descriptive terms); quantity or severity (use scales to identify intensity, 1-10); timing (onset, duration, and frequency); aggravating/ relieving factors (what makes it better or worse); associated factors (is the concern r/t any other symptom); patients perception (how does it affect them?)
Past Medical History
focus on obtaining specific pertinent information relative to each of the identified categories; more accurate and detailed information obtained will lead to better clinical decision making; record past provider plans and if the patient has followed the plan; “non compliance”
Past Medical History Includes
childhood illnesses, accident or injuries, serious or chronic illnesses, hospitalizations, operations, obstetric history, immunications, last examination date, allergies, current meds (including OTC and herbal)
Family History
highlights diseases or conditions that an individual may be at risj for as a result of genetics; provides age and health or cause of death or relatives;
Review of Systems
evaulate past and present state of each body system; assess that all pertinent data relative to each body system have been noted; evaluate health promotion practices; if info obtained in HPI, then it doesnt have to be re-assessed again; do not include objective data (limit to patient statements); include all relevant body sys
Functional Assessment
self care activities of daily living as they relate to general health status; relevant data r/t lifestyle and type of living environment; may include sensitive topics and screening tools may be used for substance and alcohol abuse
Functional Assessment Includes
activit and exercise, sleep and rest, nurtition and elimination, interpersonal relationshpis and resources, spiritual resources, coping and stress management, personal habits, illicit or street drugs, environment and work hazards, intimate partner violence, occupational health
Questions to Ask for Perception of Health
how do you define health? how do you view your situation now? what are your concerns? what are your health goals? what do you expect from us as nuses, physicians or others?
