WEEK 1: Chapter 5 Key Points The Complete Health History Flashcards
What is the purpose of the complete health history?
The complete health history serves as a foundational element in patient care. Its primary purpose is to gather detailed subjective information about the patient’s past and present health status and their lifestyle, habits, and psychosocial factors to guide clinical decision-making and individualized care planning.
Biographical Data
After you have completed your introduction, step 1 in performing the health assessment interview is collecting Biographical data.
Biographical Data includes the patient’s name, age, address, date of birth, gender and gender identity (if the patient wishes to share this information), language and communication needs or special circumstances, current occupation or daily activity pattern, recent country of residence, relationship status, or other relevant biographical data.
This step also includes recording the source of this history and who provided this information.
Reason for Seeking Care
Step 2 in performing a health assessment interview is recording the patient’s reason for seeking care.
Formerly referred to as the “chief complaint”. In the patient’s own words, briefly describe the reason for the visit. This may include the patient identifying signs and symptoms they are experiencing. If the reason for seeking care is related to any symptoms or signs the patient is experiencing, ensure to record the duration that the patient has been experiencing these. Record what the patient says. Do not translate the patient’s words into medical terms.
On occasion, the patient may list many reasons for seeking care, and the most important reason may not be the first reason listed. Try to focus on the patient’s most pressing concern by asking which one prompted the patient to seek help now.
Define symptoms & sign
-A symptom is a subjective experience reported by the patient that reflects a change from normal function, sensation, or feeling. Symptoms cannot be directly observed or measured by the healthcare provider and must be described by the individual experiencing them. They provide crucial insights into the patient’s condition and are essential for understanding the patient’s perspective on their health.
-A sign is an objective finding that can be directly observed, measured, or detected during a physical examination or diagnostic testing by the healthcare provider. Signs are tangible indicators of a condition or disease and provide measurable evidence to support a diagnosis.
Current Health or History of Current Illness
Use the mnemonic SAMPLE to aid you:
Use the mnemonic OPQRSTU to assess each symptom reported by the patient. PQRSTU stands for:
the eight critical characteristics of summarizing any symptom
