Chapter 2: Collecting Subjective Data: The Interview and Health History (Vocabulary Flashcards)

Vocabulary-style flashcards covering key terms and concepts from the interview and health history material.

Subjective data

Information provided by the client about feelings, perceptions, and experiences; not measured directly by the clinician.

Phases of the interview

Three stages: Introductory, Working, and Summary and closing.

Introductory phase

Phase where the nurse introduces self, explains the interview’s purpose, describes question types, discusses confidentiality, ensures privacy and comfort, and builds trust/rapport.

Working phase

Phase for data collection: biographical data, reasons for seeking care, history of present health concern, past health history, family history, ROS, lifestyle/health practices, and developmental level; includes listening and critical thinking and collaboration with the client.

Summary and closing phase

Phase in which information is summarized, problems/goals are validated, possible plans discussed, and any remaining concerns or questions are addressed.

Biographical data (interview context)

Identifying information such as name, address, phone, gender, birth date, place of birth, and provider of history.

Reasons for seeking care

The client’s primary motivation for seeking health care at this time.

History of present health concern

Detailed description of the current health issue, including onset, course, and symptoms.

Past health history

History of previous illnesses, surgeries, medications, allergies, and prior health problems.

Family health history

Health history of the client’s immediate and extended family, including conditions that may affect risk.

Review of body systems (ROS)

Systematic review of each body system to identify current or potential problems.

Lifestyle and health practices

Information about daily routines, nutrition, sleep, exercise, medications, substances, self-care, and related health behaviors.

Developmental level

The client’s stage of development relevant to health assessment and communication needs.

Listening, observing cues, and critical thinking

Using attentive listening and observation to interpret and validate information, and applying critical thinking to identify issues.

Collaborating with the client

Working with the client to identify problems and set achievable goals.

Nonverbal communication

Messages conveyed through appearance, demeanor, facial expression, attitude, silence, and listening.

Nonverbal communication to avoid

Avoid excessive or insufficient eye contact, distraction and distance, and standing too close or too far from the client.

Verbal communication

Use of open-ended questions, closed-ended questions, laundry list, rephrasing, well-placed phrases, inferring, and providing information.

Verbal communication to avoid

Avoid biased or leading questions, rushing through the interview, and reading the questions.

Open-ended questions

Questions that invite the client to describe feelings, thoughts, and experiences in their own words.

Closed-ended questions

Questions that require short or specific answers (e.g., yes/no or a specific option) for factual information.

Laundry list

A long list of symptoms or options presented to the client to choose from, aiding data collection.

Rephrasing

Restating the client’s statements in your own words to clarify the message.

Inferring

Interpreting cues to draw conclusions about meanings or possible issues.

Providing information

Giving the client factual details or explanations when appropriate.

COLDSPA mnemonic

A framework for symptom analysis: Character, Onset, Location, Duration, Severity, Pattern, Associated factors.

Genogram

A graphic representation of family relationships and health history used to illustrate patterns; includes Adoption signified by a vertical dotted line, spouse by a horizontal dotted line, and deceased individuals by X in a circle (female) or X in a square (male).

Adoption and genogram symbols

Vertical dotted line indicates adoption; horizontal dotted line indicates spouse; X in a circle = deceased female; X in a square = deceased male.

Health history

A comprehensive collection of data including biographical data, reasons for seeking care, history of present health concern, past health history, family health history, ROS, lifestyle and health practices, and developmental level.