1. Health History

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

3. 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
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4. 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
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5. Types of Health History
Emergency
Only gathers information required to immediately treat the emergent need of the patient
Used in life-threatening situations

6. 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

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

8. Identifying Information
Today’s date
Biographical data

9. Biographical Data Usually includes the following: Patient name Address
Telephone number
Date of birth
Birthplace
Social security number or other
Occupation
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10. Biographical Data Also includes: Work address Work telephone number
Insurance information
Usual source of health care
Source of referral
Emergency contact

11. Complete Health History
Source and reliability of information
Patient profile
Reason for seeking health care
Chief complaint (CC)
Sign
Symptom
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12. 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

13. Ten Characteristics of a Chief Complaint
Location
Radiation
Quality
Quantity
Associated manifestations
Pertinent negatives
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14. Ten Characteristics of a Chief Complaint
Aggravating factors
Alleviating factors
Setting
Timing
Meaning and impact

15. Past Health History (PHH)
Provides information on a patient’s health status from birth to present
Medical history
Chronic illness
Serious episodic illness
Sequelae
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16. Past Health History Surgical history Major procedures Minor procedures
Include year performed, hospital, physician, sequelae
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17. Past Health History Allergies Medications Animals Insect bites Foods
Environmental allergens
Symptoms, treatments, complications
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18. Past Health History Medications General questions Prescription
Over-the-counter, including herbal products
General questions
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19. 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
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20. Past Health History Injuries/accidents Special needs
Cognitive, physical, or psychosocial disabilities
Support systems
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21. 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
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22. 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
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23. Past Health History Immunizations: Child Measles, mumps, rubella Polio
Smallpox
Diphtheria, pertussis, tetanus
Haemophilus influenzae type b (Hib)
Hepatitis B
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24. Past Health History Immunizations: Adult Varicella Hepatitis A
Hepatitis B
Influenza
Tetanus
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25. Past Health History Immunizations: Adult (cont’d) Pneumococcal
Meningococcal
Shingles
Human papillomavirus
Last TB test (date and results)

26. 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
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27. Family Health History
Document information in a genogram and in a list of familial and genetic diseases
Role of genomics

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

29. 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
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30. Tips for Obtaining Sensitive Information
Adopt a nonjudgmental approach
Use communication technique of normalizing when appropriate

31. 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
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32. 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
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33. Social History Tobacco use Pack/year history Type of tobacco used
Age started to use tobacco
Quantity used daily
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34. Social History Tobacco use (cont’d) Previous attempts to quit
Self-perception of tobacco use
Live or work with smoker
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35. 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
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36. 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
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37. 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
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38. 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
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39. Social History Domestic and intimate partner violence (cont’d)
If applicable, use resources to ensure safety of patient
Document findings concisely and accurately
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40. 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
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41. 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
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42. Social History Travel history Work environment Home environment
Physical
Psychosocial
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43. Social History Hobbies and leisure activities Stress Education
Economic status
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44. Social History Military service Religion Ethnic background
Roles and relationships
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45. Social History
Characteristic patterns of daily living and functional health assessment
Normal daily timetable
Activities of daily living
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46. Social History Health maintenance activities Sleep Diet Exercise
Stress management
Use of safety devices
Health checkups

47. 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

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

49. Documentation Legal record of patient encounter
May be used by many professionals
Document in a professional and legally acceptable manner
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50. Documentation
Many institutions are using electronic medical records to document patient care information

51. 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
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52. 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
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53. 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)
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54. 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

55. 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
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56. Assessment-Specific Documentation Guidelines
Avoid evaluative statements; cite specific statements or actions you observe
State time intervals precisely
Use specific measurements
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57. 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