The complete health history

* collect subjective data * combing subjective data w/ objective data from the physical exam & diagnostic tests, you create a database to make a judgement about the person's health status * 8 categories

health history includes a detailed, chronological record of the health problem

* a screening tool for abnormal symptoms, health problems, & concerns * records the patient's responses to health problems

* patient's name * address * date of birth * language & communication needs

* usually the patient * may be someone else, such as relative or interpreter

* formerly known as chief of complaint * in patient's own words, briefly describe the reason for visit * write this in quotes

* well person- briefly note the general state of health * sick person- chronologically record the reason for seeking care

* when a patient reports a symptom * PQRSTU

provocative or palliative

quality or quantity

region or radiation

severity scale

timing

understanding the patient's perception of the problem

illnesses, injuries, hospitalizations, allergies, & current medications

* to help detect health risks for the patient * draw a pedigree or genogram

* to evaluate the past & present health of each body system, double check for significant data, & assess health promotion practice * for each body system, assess for symptoms & health promoting behaviors

Include activities of daily living Example: bathing dressing, toileting, eating, walking, housekeeping, shopping, cooking

* obtained for each health history category * may vary from one setting to another * address all categories before making a diagnosis or judgement about the patient's health status

* use same structure as adult * make some modifications: a prenatal & perinatal history, the parent's description of the present problem, any childhood illnesses or accidents, immunization data, a developmental overview, and a nutritional history

consider child's environment & his/her function or role in the environment

* ask additional questions * for example: explore changes in activities of daily living that may result from the aging process or chronic illness

* may be more important to an older adult than the actual disease diagnosis or pathology * be sure to record the person's reason for seeking care, not your assumption of the problem

useful because it addresses: * basic & instrumental activities of daily living * functional assessment * physical, social, psychologic, demographic, financial, & legal issues