Unit 2B.2: Collecting Subjective Data | Health History, History of Present Illness, Gordon's

Health History

Collection of information obtained from the patient or other sources

1. Provide subjective database

2. Identify patient strengths

3. Identify patient health problems (actual and potential)

4. Identify supports

5. Identify teaching needs

6. Identify discharge needs

7. Identify referral needs

7 Purposes of Health History

1. Biographical Data

2. Source of History

3. Present Health History

4. Past Health History

5. Gordon’s Functional Health Patterns

5 Components of Health History

In for complaints of (main symptom) noted (onset) accompanied by (associated symptoms).

How to format chief complaint?

1. Fever

2. Pain

3. Cough

4. Vomiting

5. Diarrhea

6. Masses

7. Injuries

7 Common Chief Complaints (Check Knowt 2B.1 for specifics about Chief Complaints)

COLDSPA

Acronym for the History of Present Illness

Character

Onset

Location

Duration

Severity

Pattern

Associated Signs and Symptoms

COLDSPA

1. Chronological account (begin with PTA/PTC)

2. Consultations or tests taken?

   1. Date?

   2. Results?

   3. Who ordered?

3. Medications taken?

   1. Generic and brand name, dosage, frequency?

   2. Temporary or permanent relief?

4. Other management done?

5. Pertinent negatives?

6. Concluded with explanation why patient came to the hospital

What should be included in the History of Present Illness (HPI)?

Marjory Gordon

Who created the Gordon’s Functional Patterns?

1. Health Perception - Health Management

2. Nutritional - Metabolic

3. Elimination

4. Activity - Exercise

5. Sleep - Rest

6. Cognitive - Perceptual

7. Self-Perception - Self Concept

8. Role - Relationship

9. Sexuality - Reproductive

10. Coping - Stress Tolerance

11. Value - Belief

11 Health Patterns