Health History

Subjective information

what the patient says

ALL Health History parts are

Subjective Information

Types of Health Histories

• Comprehensive

• Focused or problem-oriented

  • Follow-up

  • Emergency

Comprehensive

When: New Patients

How: All questions

Who: Depends on location

Why: To get a full picture of the patient’s health status

Focused or Problem-oriented

When: The patient is known

How: Focuses on main issue(s) - not all questions

Why: We already know the other parts… we just need to know the current problem(s)

Focused: Emergency

When: Emergencies

How: Focused history, rapid

Why: To not delay care; decrease morbidity

Focused Follow- up

When: The patient needs to return

How: Focused

Why: Was treatment effective or not

Health History Components

• Identifying data and source

• Chief complaint(s)

• History of present illness (HPI)

• Past medical/surgical history

• Family history

• Review of systems

• Health patterns

Identifying Data and history source

• Name

• Age

• Gender

• Birthday

• Marital/relationship status

• Occupation

• Education level

• Primary language

Chief Complaint (CC)

Symptoms, concerns, goals

quote what patients says

History of Present illness (HPI)

Tells more about the CC

OLDCART

Onset

Location

Characteristics

Associated symptoms

Relieving/Exacerbating symptoms

Treatment

Onset

When did the pain begin? Does it occur at a specific time of day?

Location

Ask the patient to point to the pain. Ask about radiation of pain.

Duration

Is it constant? Does it come & go?

Characteristic

Severity of pain — use appropriate pain scale. Describe pain — sharp, dull burning, aching, etc. Does it follow a particular pattern?

Associated manifestations

Does anything occur when you experience the pain? Nausea, vomiting, headaches, itching, burning, sweating

Relieving Factors

What makes the pain better? What makes it worse?

Treatment

What have you done to try to make it better? Have you consulted a provider?

Other information or comments:

What do you think is causing the pain?

Past Medical History

• Allergies (include reaction)

• Medications

• Childhood illness

• Medical (any issue)

• Health maintenance (sleep, diet, activity)

Asking about drugs, alcohol, abuse issues

• leave judgment out of the question

• be matter of fact and ask like you asked about other things

Family History

• Can ID diseases the patient is at risk for

• Drives education and screening

Review of Systems (ROS)

Clinic setting: often the client may fill out; nurse will clarify discrepancies

Hospital setting: RN/LPN completes; Head to Toe history (All Subjective)

SYSTEMS

HEENT, Neck, Breasts, Respiratory, Cardio/peripheral vascular, Gastrointestinal, Urinary, Reproductive, Musculoskeletal, Integument, Neurological, Psychiatric, Hematologic, Endocrine

Health Practices

ID values, routines, changes, motivation

• self-perceptions/self-concept

• value-belief

• activity-exercise

• sleep-rest

• nutrition

• role-relationship

• coping-stress-tolerance

Communication Tips

most important rule is to be nonjudgemental

explain why you need to know certain information

find opening questions for sensitive topics and learn the specific kinds of information needed for your assessments

Sexual History

• determine risk

• sexual practice may be related to symptoms

• sexual dysfunction may result from medication or misinformation

Mental Health History

• be aware of cultural construct

• be sensitive to reports of mood changes or depression

• ask open-ended, ask about medication

Family Violence

Many authorities recommend routine screening for domestic violence

If abuse is suspected, it is important to spend part of encounter alone with the patient

Do not force the situations

Physical abuse should be considered in the following situations:

• injuries type and frequency

• treatment delay

• alcohol or drug use disorder

• actions of partner or person in room is suspicious