11 terms

1155 Health history

what is the purpose of a health history
primarily subjective
1. obtain info - one question leads to more questions
2. ID risks = allergies, family, lifestyle, health habits
3. resolve problems
4. promote health
5. prevent disease
6. establish relationships = helpful, therapeutic relationships
what should you do prior to interview with patient?
1. ensure privacy = who is in the room, close the door
2. meet patient's psychological needs = explanations, how long will this take, face-to-face, assess for anxiety
3. meet patient's physical needs = lighting, bathroom, pain, warmth
4. consider culture/age/gender
What are the 3 interview phases?
1. introduction = name, purpose
2. discussion = collect data
3. summary = clarifying, validating (what you see & hear, verbal & non-verbal)
What are the different history types (3)?
1. Problem oriented/focused = limited to a problem, but detailed as to cause & effect
2. Episodic/follow up = focuses on a treated problem & what happened. Return well visit. monitor & follow up
3. Comprehensive = annual exam, initial encounter
a. biographical data (name, age, address, etc)
b. reason seeking care = CC or presenting problem (if it is acute history might stop here)
What is medical history?
conditions, medications, surgery, illnesses, allergies, etc...
What is family history?
- biological parents, aunts, uncles, siblings
- many will include grandparents, spouse, children (Bonnie includes these)
- dementia, heart, lung, kidney, diabetes, obesity, cancer
What are two types of lifestyle?
1. Personal = culture, religion, work, support, socialization, alcohol, drugs, diet, tobacco, exercise
2. Psychological = stressors, supports, how do you react to stress, coping mechanisms.
- Ask specific questions & don't accept answers such as occasional, seldom, social
What is review of systems
it is a history by system, such as, respiratory, cardiac, GI, etc...
What is functional health history?
- health perception-health management pattern
- nutritional metabolic pattern
- elimination
- activity exercise
- cognitive
- sleep rest
- self-perception, self-concept
- role relationship
- sexuality reproductive
- coping, stress, tolerance
- value, belief
What six things shouldn't you do when taking a health history?
1. excessive or insufficient eye contact
2. crowd or distance yourself from the patient
3. stand (while they are sitting)
4. Ask biased or leading questions (You don't smoke, do you?)
5. Rush
6. Read the questions - just ask the questions & then review the forms to see what you missed
Once you collect the data you must?
1. Organize = usually you have some sort of form
2. Synthesize = interpret, analyze, make sense of it
3. Document the answers, if you didn't assess something write "not asked, not assessed"