What is the purpose of the complete health history?
To collect subjective data (what the patient says) that, when combined with objective data and lab studies, forms a database for diagnosis.
How is health history used for well patients?
To assess lifestyle, encourage healthy behaviors, and affirm what the patient is doing right.
How is health history used for ill patients?
As a detailed, chronological record of the health problem.
How is health history used for all patients?
As a screening tool for abnormal symptoms, health problems, and concerns, and to record health promotion behaviors and coping skills.
What are the eight categories of data collected in the health history?
1) Biographic data, 2) Source of history, 3) Reason for seeking care, 4) Present health/history of present illness, 5) Past health, 6) Family history, 7) Review of systems, 8) Functional assessment.
What are examples of biographic data?
Name, date of birth, occupation, primary language, and communication needs.
What is the usual source of health history?
The patient.
What is the ‘reason for seeking care’?
The patient’s brief statement, in their own words, of one or two symptoms/signs and their duration.
How is present health recorded for a well person?
A brief note of general health.
How is present health recorded for a sick person?
Chronological account of the reason for seeking care.
What is included in a symptom analysis?
Location, character/quality, quantity/severity, timing, setting, aggravating/relieving factors, associated factors, and patient’s perception.
What does PQRSTU stand for?
Provocative/palliative, Quality/quantity, Region/radiation, Severity scale, Timing, Understand patient’s perception.
What is included in past health history?
Childhood illnesses, serious/chronic diseases, accidents, hospitalizations, operations, obstetric history, immunizations, allergies, last exam date, and medications.
What is the purpose of family history in health assessment?
To detect health risks, guide screening, and plan surveillance.
What additional questions may be asked during health history?
Spiritual/religious resources, nutrition, and immigration status.
What is the purpose of a review of systems?
To evaluate past/present health of each body system, double-check for missing data, and assess health promotion practices.
What is included in a functional assessment?
Activities of daily living, self-care ability, self-esteem, self-concept, psychosocial aspects (substance use, IPV), and environmental factors (occupational health).
How should a child’s health history be obtained?
Use the adult structure with modifications.
What additions are included in a child’s health history?
Prenatal/perinatal history, family unit description, present problem and informant, childhood illnesses, immunizations, injuries/accidents, surgeries/hospitalizations, medications, allergies, developmental milestones, and nutritional history.
What should be considered when assessing a child’s functional abilities?
The child’s environment and their role/function in it.
What method is used to assess an adolescent’s psychosocial state?
The HEEADSSS method.
What does HEEADSSS stand for?
Home environment, Education/employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, and Safety (including driving).
