Health Assessment -- (EXAM I) The Complete Health History

purpose of health history

- collect subjective data to combine with objective data from physical exam and lab studies to form a database

- provides a complete picture of patient's past and present health status

- sequence may vary in terms of obtained information

- focus may differ in terms of clinical practice setting

symptom

subjective sensation person feels from disorder documented in quotes

sign

objective abnormality that can be detected on physical examination or in laboratory reports

reasons for seeking care

focus on patient's prioritized reasons for seeking care

present health or history of present illness (HPI)

collect all provided data and identify eight critical characteristics (PQRST or COLDSPA)

PQRST or COLDSPA

1. location: be specific and precise

2. character or quality: provide descriptive terms

3. quantity or severity: use scales to identify intensity

4. timing: onset, duration, and frequency

5. setting: location and/or associated activity

6. aggravating or relieving factors: what makes it worse or better

7. associated factors: is the concern r/t any other symptom?

8. patient's perception—how does it affect you?

- use measurable standards and/or the patient's own words as qualifiers.

- use standardized indicators to document findings

PQRSTU mnemonic

- p: provocative or palliative

- q: quality or quantity

- r: region or radiation

- s: severity scale: 1 to 10

- t: timing or onset

- u: understand the patient's perception of the problem

purpose of review of systems (ROS)

- evaluate the past and present state of each body system

- assess that all pertinent data relative to each body system have been noted

- evaluate health promotion practices

cephalocaudal approach to ROS

organized manner proceeding in a logical sequence

review of systems (ROS): what to focus on & avoid

- do not include objective data; limit to patient statements or subjective data

- include all relevant body systems; focus on health promotion for each identified area