Module 1 Chapter 4: Health History Flashcards
What is a complete health history?
- 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
Health history Sequence (first 7)
- 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)
(Next 8 of health history sequence)
- Psychosocial assessment • Review of systems (ROS) • Physical examination (PE) • Pain assessment
- Development assessment
- Cultural and spiritual assessment • Substance use assessment
- Assessment of human violence
(Last 3 of health history)
• Pre-interaction (preparing for the interview) • Introduction
• Working phase (data-gathering phase)
– Open-ended and direct questions
• Closing – should be seamless for patient
Health history is what kind of data
subjective
What is Biographical data?
• Name • Address • Phone number • Date of birth • Age • Gender • Marital status • Race • Ethnic origin • Language preferred • Authorized representative • Occupation • Religious preference • Insurance information
Source of reliability
- who gave the info
- who accompanied the patient
- judge how reliable the information seems
Chief complaint
- reason for seeking care
- ‘‘Should be in quotes! in patient’s own words’’
History of Present Illness
- 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
Parts of HPI
- 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
what does the acronym OLDCARTS stand for
- Onset
- L ocation
- D uration
- C haracter
- A lleviating/aggravating • R adiation
- Timing
- S everity
What does a functional assessment do?
Assess the patient’s ability to self-care
What is included in the psychosocial assessment?
Social roles • Spiritual resources • Coping and stress management • Sexual history • Personal habits – Smoking – Alcohol – Recreational drugs
What comes after the Psychosocial assessment?
- Review of Systems
ROS
- from head to toe
• Notethepresenceorabsenceofsymptoms
• Any problems detected need to be carefully described
What are the 3 levels of prevention?
Primary
Secondary
tertiary
Primary prevention
Reduction of risk factors before occurrence of disease, condition or injury
Secondary Prevention
Early detection of the disease while asymptomatic or the potential for development of a disease
Tertiary Prevention
Treatment of a disease to delay or prevent progression
