Module 1 Chapter 4: Health History Flashcards
1
Q
What is a complete health history?
A
- Printed form or checklist filled out by patient
- Form allows patient time to remember dates, etc.
- Interview performed to validate, clarify and expand on written data
2
Q
Health history Sequence (first 7)
A
- Biographical data
- Source and reliability of history
- Reason for seeking care “chief concern” • History of present illness (HPI)
- Past history
- Family history
- Functional assessment (ADLs)
3
Q
(Next 8 of health history sequence)
A
- Psychosocial assessment • Review of systems (ROS) • Physical examination (PE) • Pain assessment
- Development assessment
- Cultural and spiritual assessment • Substance use assessment
- Assessment of human violence
4
Q
(Last 3 of health history)
A
• Pre-interaction (preparing for the interview) • Introduction
• Working phase (data-gathering phase)
– Open-ended and direct questions
• Closing – should be seamless for patient
5
Q
Health history is what kind of data
A
subjective
6
Q
What is Biographical data?
A
• Name • Address • Phone number • Date of birth • Age • Gender • Marital status • Race • Ethnic origin • Language preferred • Authorized representative • Occupation • Religious preference • Insurance information
7
Q
Source of reliability
A
- who gave the info
- who accompanied the patient
- judge how reliable the information seems
8
Q
Chief complaint
A
- reason for seeking care
- ‘‘Should be in quotes! in patient’s own words’’
9
Q
History of Present Illness
A
- sosmeone who is well will just give an overall statement of their health. Some one who is ill, the 8 criticsl elements will be needed
10
Q
Parts of HPI
A
- Location
- Character or quality
- Quantity or severity
- Timing(onset, duration, frequency)
- Setting (where was the patient, what brought it on)
- Aggravating or relieving factors
- Associated factors
- Patient’s perception
11
Q
what does the acronym OLDCARTS stand for
A
- Onset
- L ocation
- D uration
- C haracter
- A lleviating/aggravating • R adiation
- Timing
- S everity
12
Q
What does a functional assessment do?
A
Assess the patient’s ability to self-care
13
Q
What is included in the psychosocial assessment?
A
Social roles • Spiritual resources • Coping and stress management • Sexual history • Personal habits – Smoking – Alcohol – Recreational drugs
14
Q
What comes after the Psychosocial assessment?
A
- Review of Systems
15
Q
ROS
A
- from head to toe
• Notethepresenceorabsenceofsymptoms
• Any problems detected need to be carefully described
