1. The Complete Health History Including Documentation
Chapter 3
The Complete Health History Including Documentation
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2. Copyright 2002, Delmar, A division of Thomson Learning
Competencies
State the purpose of the four different types of health history and provide an example of when each is used.
Identify the components of the complete health history.
Describe how to assess the ten characteristics of a chief complaint.
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Competencies
Diagram a patient’s genogram correctly.
Demonstrate sensitivity to patients of different races, religions, ethnic backgrounds, sexual orientations, and socioeconomic status when conducting a health history.
Conduct a complete health history on ill and well patients and record data.
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4. Types of Health History
Provides information on the patient’s health status: social, emotional, physical, cultural, and spiritual identity
Complete health history
Episodic health history
Interval or follow-up health history
Emergency health history
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5. Identifying Information Included in Medical Record
Patient name
Address
Occupation
Insurance
Phone number
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6. Identifying Information Included in Medical Record
Usual source of health care
Date of birth
Birth place
Emergency contact
Social security number
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7. Complete Health History
Patient profile
Reason for seeking health care
Chief complaint (CC)
Sign
Symptom
Present health and history of present illness (HPI)
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8. Ten Characteristics of a Chief Complaint
Location
Radiation
Quality
Quantity
Associated manifestations
Pertinent negatives
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9. Ten Characteristics of a Chief Complaint
Aggravating factors
Alleviating factors
Setting
Timing
Meaning and impact
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10. Past Health History (PHH)
Provides information on the patient’s health status from birth to present
Medical history
Chronic illness
Episodic illness
Sequelae
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Past Health History
Surgical history
Major procedures
Minor procedures
Include year performed, hospital, physician, sequelae
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Past Health History
Medications
Prescription
Over-the-counter
Herbs
Home remedies
General questions
Dose
Frequency
Side effects
Purpose
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Past Health History
Communicable diseases
Infectious
Pertussis
Tuberculosis
Hepatitis
AIDS
Sexually transmitted
Gonorrhea
Syphilis
Chlamydia
Herpes
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Past Health History
Allergies
Medications
Food
Animals
Environment
Symptoms
Treatment
Complications
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Past Health History
Injuries/accidents
Special needs
Blood transfusions
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Past Health History
Childhood illnesses
Varicella
Diptheria
Measles, mumps, rubella
Polio, rheumatic or scarlet fever
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Past Health History
Immunizations: childhood
MMR
Polio
Smallpox
DPT
Haemophilus influenza b (Hib)
Hepatitis B
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Past Health History
Immunizations: adult
Varicella
Hepatitis A
Hepatitis B
Influenza
Tetanus
Pneumococcal
Lyme
Meningococcal
Last TB test (date and results)
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19. Family Health History (FHH)
Records the health status of the patient and immediate blood relatives.
Contains age and health status of the patient, spouse, children, siblings, and the patient’s parents.
Document information in a genogram and in a list of familial diseases.
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Social History (SH)
Records information about the patient’s lifestyle that may impact health
Tips for obtaining information
Establish rapport
Direct eye-contact
Pose questions in a matter of fact tone
Nonjudgmental demeanor
Normalizing
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Social History
Alcohol use
Thorough assessment to include:
Quantity of alcohol consumed
Frequency of consumption
Age at first drink
Pattern of consumption
Length of time consuming current amount
History of loss of consciousness or blackouts
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22. Copyright 2002, Delmar, A division of Thomson Learning
Social History
Time of day when drinking occurs
Drink alone or with others
Drink and drive
Self perception of drinking
CAGE questionnaire (Mayfield, McLeod & Hall, 1974)
Have you ever felt you should cut down on your alcohol intake?
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Social History
Have people annoyed you by criticizing your alcohol intake?
Have you ever felt guilty about your alcohol intake?
Have you ever needed alcohol for an eye-opener (morning consumption)?
Tobacco use
Pack/year history
Type of tobacco used
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Social History
Age started to use tobacco
Quantity used on daily basis
Previous attempts to quit
Self-perception of tobacco use
Live or work with smoker
Drug use
Prescription and over-the-counter medications
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Social History
Illegal and recreational drugs
Same types of questions used for determining alcohol use
Sexual practices, specific questions
Sexual orientation
Past sexual practice
Number of partners
Birth control method
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Social History
Measures to prevent exchange of body fluids
Presence of STDs
Satisfaction with sexual performance/needs
Travel history
Work environment
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Social History
Home environment
Physical
Psychosocial
Hobbies or leisure activities
Stress
Education
Economic status
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Social History
Military service
Religion
Ethnic background
Roles/relationships
Functional health assessment
Activities of daily living
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Social History
Health maintenance activities (HMA)
Sleep
Diet
Exercise
Stress management
Use of safety devices
Health check-ups
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30. Review of Systems (ROS)
Cephalo-caudal approach
Questions
Sign/symptom related
Disease related questions
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31. Documentation Guidelines
Ensure accuracy
Record information immediately upon completion of patient encounter
Correct patient record or chart
Avoid distractions while documenting
Proofread your entry for accuracy and completeness
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32. Documentation Guidelines
Date and time each entry
Sign each entry with full legal name and professional credentials
Write legibly
Use permanent ink (black preferred)
Do not leave a space between entries
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33. Documentation Guidelines
Use quotes to indicate direct patient response
Document in chronological order
Document in complete but concise manner using phrases and abbreviations as appropriate
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34. Documentation Guidelines
Document telephone calls that relate to the patient’s case
Never correct another person’s entry
Use a single line to cross out an error, then date, time and sign correction
If it is not documented, it was not done
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35. Assessment-Specific Documentation Guidelines
Record pertinent positive and negative assessment data
Document any parts of the assessment that are omitted or refused by the patient
Avoid using judgmental language
Avoid evaluative statements; cite specific statements or actions you observe
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36. Assessment-Specific Documentation Guidelines
State time intervals precisely
Use specific measurements
Draw pictures when appropriate
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37. Assessment-Specific Documentation Guidelines
Refer to findings using anatomic landmarks
Use the face of a clock to describe findings that are in a circular pattern
Document any change in the patient’s condition during a visit or from previous visits
Describe what you observed, not what you did
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