Health History

Health History A patient’s health history includes the following: Health status Social, emotional, physical, cultural, and spiritual identity

Types of Health History Complete Comprehensive history of patient’s past and present health status Episodic Specific to the patient’s current reason for seeking health care (continues)

Types of Health History Interval or follow-up Builds on a preceding visit to a health care facility May document recovery from illness or progress from previous visit (continues)

Types of Health History Emergency Only gathers information required to immediately treat the emergent need of the patient Used in life-threatening situations

Preparing for the Health History Requires 30 to 60 minutes Validate health history information provided by the patient prior to interview Some information may be obtained from medical records and updated during interview

Computerized Health History Two types: Patient generated Health care provider generated Often user-friendly and time-saving

Identifying Information Today’s date Biographical data

Biographical Data Usually includes the following: Patient name Address Telephone number Date of birth Birthplace Social security number or other Occupation (continues)

Biographical Data Also includes: Work address Work telephone number Insurance information Usual source of health care Source of referral Emergency contact

Complete Health History Source and reliability of information Patient profile Reason for seeking health care Chief complaint (CC) Sign Symptom (continues)

Complete Health History Present health and history of present illness (HPI) HPI is a chronological account of the patient’s CC and the events surrounding it

Ten Characteristics of a Chief Complaint Location Radiation Quality Quantity Associated manifestations Pertinent negatives (continues)

Ten Characteristics of a Chief Complaint Aggravating factors Alleviating factors Setting Timing Meaning and impact

Past Health History (PHH) Provides information on a patient’s health status from birth to present Medical history Chronic illness Serious episodic illness Sequelae (continues)

Past Health History Surgical history Major procedures Minor procedures Include year performed, hospital, physician, sequelae (continues)

Past Health History Allergies Medications Animals Insect bites Foods Environmental allergens Symptoms, treatments, complications (continues)

Past Health History Medications General questions Prescription Over-the-counter, including herbal products General questions (continues)

Past Health History Communicable diseases Hepatitis Diphtheria, tetanus, or pertussis Tuberculosis HIV/AIDS exposure Sexually transmitted diseases Ask about tattoos and piercings Ask about exposure to communicable diseases (continues)

Past Health History Injuries/accidents Special needs Cognitive, physical, or psychosocial disabilities Support systems (continues)

Past Health History Blood transfusions Patients who receive a large number of transfusions are at greatest risk for blood-borne infections American Red Cross screens donors and tests blood for hepatitis, HIV, and West Nile virus (continues)

Past Health History Childhood illnesses Varicella Diphtheria Measles, mumps, rubella Polio, rheumatic fever, or scarlet fever Determine age at onset of illness and presence/absence of complications (continues)

Past Health History Immunizations: Child Measles, mumps, rubella Polio Smallpox Diphtheria, pertussis, tetanus Haemophilus influenzae type b (Hib) Hepatitis B (continues)

Past Health History Immunizations: Adult Varicella Hepatitis A Hepatitis B Influenza Tetanus (continues)

Past Health History Immunizations: Adult (cont’d) Pneumococcal Meningococcal Shingles Human papillomavirus Last TB test (date and results)

Family Health History (FHH) Records the health status of patient and immediate blood relatives Contains age and health status of patient and patient’s spouse, children, siblings, and parents (continues)

Family Health History Document information in a genogram and in a list of familial and genetic diseases Role of genomics

Social History (SH) Records information about patient’s lifestyle that may affect health Explain why this information is important

Tips for Obtaining Sensitive Information Ask questions after rapport and trust are established with the patient Use direct eye contact Use a matter-of-fact tone when asking questions (continues)

Tips for Obtaining Sensitive Information Adopt a nonjudgmental approach Use communication technique of normalizing when appropriate

Social History Alcohol use Thorough assessment to include the following: Quantity of alcohol consumed Frequency of consumption Type of alcohol (including homemade) Age at first drink Length of time consuming current amount (continues)

Social History Alcohol use (cont’d) Thorough assessment (cont’d) Pattern of current consumption History of loss of consciousness or blackouts Drink alone or with others Drink and drive Drinking during pregnancy Self-perception of drinking (continues)

Social History Tobacco use Pack/year history Type of tobacco used Age started to use tobacco Quantity used daily (continues)

Social History Tobacco use (cont’d) Previous attempts to quit Self-perception of tobacco use Live or work with smoker (continues)

Social History Drug use Prescription and over-the-counter medications Illegal and recreational drugs Marijuana, amphetamines, uppers, downers, cocaine, crack, heroin, PCP, inhalants, “club” drugs (continues)

Social History Drug use (cont’d) Ask the patient the same types of questions used for determining alcohol use Goal is to obtain data on what substances are used, and the pattern of substance use (continues)

Social History Domestic and intimate partner violence (IPV) Crosses racial, cultural, geographic, and socioeconomic lines Nurse must adhere to state reporting laws Includes physical, psychological, emotional, sexual, and financial abuse or coercion (continues)

Social History Domestic and intimate partner violence (cont’d) Use technique of normalizing Use a single, broad question to screen for domestic and IPV Ask whether patient feels safe in current environment (continues)

Social History Domestic and intimate partner violence (cont’d) If applicable, use resources to ensure safety of patient Document findings concisely and accurately (continues)

Social History Domestic and intimate partner violence (cont’d) Warning signs Frequent injuries/accidents/burns Previous injuries for which patient did not seek care Refusal to discuss injury Presence of significant other who answers for patient Significant other with a history of violence or substance abuse (continues)

Social History Sexual practice Sexual orientation Past sexual practice Age at first sexual experience Number of partners Birth control method Measures to prevent exchange of body fluids (continues)

Social History Travel history Work environment Home environment Physical Psychosocial (continues)

Social History Hobbies and leisure activities Stress Education Economic status (continues)

Social History Military service Religion Ethnic background Roles and relationships (continues)

Social History Characteristic patterns of daily living and functional health assessment Normal daily timetable Activities of daily living (continues)

Social History Health maintenance activities Sleep Diet Exercise Stress management Use of safety devices Health checkups

Review of Systems (ROS) Head to Toe Assessment Types of questions Sign- and symptom-related questions Disease-related questions Document positive and pertinent negative findings

Concluding the Health History Ask patient whether there is additional information to discuss Thank patient Tell patient the next step

Documentation Legal record of patient encounter May be used by many professionals Document in a professional and legally acceptable manner (continues)

Documentation Many institutions are using electronic medical records to document patient care information

Documentation Guidelines Ensure accuracy Ensure correct patient record or chart Record information immediately upon completion of patient encounter Avoid distractions while documenting Date and time each entry (continues)

Documentation Guidelines Sign each entry with full legal name and professional credentials Do not leave a space between entries Use a single line to cross out an error, then date, time, and sign correction Never correct another person’s entry (continues)

Documentation Guidelines Use quotes to indicate direct patient response Document in chronological order If entries are hand-written Write legibly Use permanent ink (black preferred) (continues)

Documentation Guidelines Document in complete but concise manner, using phrases and abbreviations as appropriate Document telephone calls that relate to patient’s case Legal standard for documentation If it is not documented, it was not done

Assessment-Specific Documentation Guidelines Record pertinent positive and negative assessment data Document any parts of the assessment that are omitted or refused by patient Avoid using judgmental language (continues)

Assessment-Specific Documentation Guidelines Avoid evaluative statements; cite specific statements or actions you observe State time intervals precisely Use specific measurements (continues)

Assessment-Specific Documentation Guidelines Document any change in patient’s condition during a visit or from previous visits Describe what you observed, not what you did