Ill person’s history includes a detailed, chronological record of the health person.
All history’s include abnormal symptoms, health problems and concerns.
2. source of history – patient, family, interpreter,
3. Reason for seeking care – 1 or 2 symptoms and duration,
4. Present health/history of present illness with symptom analysis,
5. Past health events – injuries, hospitalizations etc.
6. Family history,
7. Review of body systems,
8. Functional assessment – ADL’s etc.
Education and employment,
Safety from injury/violence.
1. Prenatal/perinatal history
2. Issue description and who provided the details,
3. Childhood illness, accidents and shots,
4. Developmental overview,
5. Nutritional history,
Consider developmental age in functional assessment.
Consider in ADL’s due to having or chronic health changes.
Impact or burden of the disease.
1. Location- precise location of issue,
2. Character/quality- sharp, dull, burning, aching, etc.,
3. Quantity/severity- use pain scale, dressing changes, etc,
4. Timing- onset, duration, frequency
5. Setting- issue associated location or activities,
6. Aggravating or relieving factors- what makes it worse, brings it on, or makes it better.
7. Associated factors- other related symptoms/causes,
8. Patient’s perception- impacts/meaning to patients life.
P: Provocative/palliative – What brings it on? Activity happening when you first noticed it? What makes it better? Worse?
Q: Quality/quantity – How severe is it? Look, feel, sound?
R: Region/radiation – Where is it? Does it spread out?
S: Severity scale – Rating on scale? Is it improving/worsening?
T: Timing = When did it start? How long? How often?
U: Understand patients perception- What do you think it means?
2. Present health state- statement about the general state of health.
3. Past history- important since they may have residual effects on the current health state.
4. Review of systems- evaluate past & present health state of each body system.
5. Functional patterns of living- measures a persons self care ability.
2. double check incase any significant data were omitted in the present illness section.
3. evaluate health promotion practices.