The complete health history

The complete health history

Purpose of complete health history
* collect subjective data
* combing subjective data w/ objective data from the physical exam & diagnostic tests, you create a database to make a judgement about the person’s health status
* 8 categories
Sick patients
health history includes a detailed, chronological record of the health problem
All patients
* a screening tool for abnormal symptoms, health problems, & concerns
* records the patient’s responses to health problems
Biographic data
* patient’s name
* address
* date of birth
* language & communication needs
Source of history
* usually the patient
* may be someone else, such as relative or interpreter
Reason for seeking care
* formerly known as chief of complaint
* in patient’s own words, briefly describe the reason for visit
* write this in quotes
Present health or history of present illness
* well person- briefly note the general state of health
* sick person- chronologically record the reason for seeking care
Symptom analysis
* when a patient reports a symptom
* PQRSTU
P
provocative or palliative
Q
quality or quantity
R
region or radiation
S
severity scale
T
timing
U
understanding the patient’s perception of the problem
Past health events
illnesses, injuries, hospitalizations, allergies, & current medications
Family history
* to help detect health risks for the patient
* draw a pedigree or genogram
Review of systems
* to evaluate the past & present health of each body system, double check for significant data, & assess health promotion practice
* for each body system, assess for symptoms & health promoting behaviors
Functional assessment
Include activities of daily living
Example: bathing dressing, toileting, eating, walking, housekeeping, shopping, cooking
Depth of information
* obtained for each health history category
* may vary from one setting to another
* address all categories before making a diagnosis or judgement about the patient’s health status
Child’s health history
* use same structure as adult
* make some modifications: a prenatal & perinatal history, the parent’s description of the present problem, any childhood illnesses or accidents, immunization data, a developmental overview, and a nutritional history
Assessing child’s functional ability
consider child’s environment & his/her function or role in the environment
Older adult’s health history
* ask additional questions
* for example: explore changes in activities of daily living that may result from the aging process or chronic illness
Impact or burden of a disease
* may be more important to an older adult than the actual disease diagnosis or pathology
* be sure to record the person’s reason for seeking care, not your assumption of the problem
Comprehensive older person’s evaluation
useful because it addresses:
* basic & instrumental activities of daily living
* functional assessment
* physical, social, psychologic, demographic, financial, & legal issues