The purpose of the complete health history
to collect subjective data
Critical characteristics used to explore each symptom the patient identifies.
1. location- ask the pt. to point to the location
2. character or quality- specific descriptive terms
3.Quantity or severity- qualify the sign or symptom
4.Timing- onset, duration, frequency
5. Setting- where were you
6. Aggravating or relieving factors- what makes it worse, brings it on, or makes it better.
7.Associated factors- primary symptom associated with any others.
8. Patient's perception- meaning of the symptom to the patient
Elements of the health history:
1. Reason for seeking care- brief, spontaneous statement in pt.'s own words.
2.Present health state- statement about the general state of health
3. Past history- important b/c they may have residual effects on the current health state.
4. Review of systems- evaluate past & present health state of each body system.
5. Functional patterns of living- measures a persons self care ability.
Rational for obtaining a family history
to highlight those diseases and conditions for which a particular pt. may be at increased risk for.
Pedigree or genogram
a graphic family tree in at least 3 generations such as parents, grandparents, and siblings.
Rationale for obtaining a systems review
1. evaluate the past and present health state of each body system
2. double check incase any significant data were omitted in the present illness section.
3. evaluate health promotion practices.
Items included in a functional assessment
spiritual resources, activity/ exercise, sleep/rest, nutrition/ elimination, coping/ stress management, self esteem, self concept, interpersonal relationships, personal habits, occupational health, environmental hazard, and alcohol or illicit street drugs.
One way to verify the reliability within the context of the interview is to:
rephrase the same question later in the interview.
During an initial interview, the examiner says, "Mrs. J' tell me what you do when your headaches occur." With this question the examiner is seeking information about:
aggravating or relieving factors
Which of the following of an appropriate recording of a patent's reason for seeking health care?
"grabbing" chest pain for 2 hr
Select the best description of "review of systems" as part of the health history.
the evaluation of the past and present health state of each body system
Which of the following is considered to be subjective?
pain lasting 2 hours
