The purpose of the complete health history
To collect
subjective data
. Which is what the person says about himself or herself.
By combining this subjective data with objective data from the PE & diagnostic tests, you create a database to make a judgment about the person's health status.
No matter what form is used to record the health history, plan to gather data in 8 categories
1. Biographical data
2. Source of history
3. Reason for seeking care
4. Present health history/ illness
5. Past health info
6. Family history
7. Review of systems
8. Cultural/ADLs
Taking an older adult's health history
Ask additional questions. For example, explore changes in activities of daily living that may result from aging process or chronic illness. Remember the impact or burden of a disease may be more important to an older adult rather than the actual disease,
To determine patients perception of pain
Nurse would determine the meaning of the symptom by asking how it affects ADLs & what the pt thinks the pain means. Known pt's culture it can also influence their pain tolerance.
CAGE screening questionnaire
C=Cut down, A=Annoyed, G=guilty, E=eye opener
The reason for seeking care
a statement in the person's own words that describes the reason for the visit. Replaced "chief of care" to incorporate wellness needs
Presence or Absence of symptoms list
P=provocative or palliative
Q=quality or quantity
R=region or radiation
S=severity scale
T=timing
U=understanding patient's perception
Reliable person
will always give same answers, even when questions are rephrased or repeated later in the interview
Adolescent interview
Should be with youth alone; the parent(s) may wait in the waiting area & complete other past health questionnaire forms
The purpose of the complete health history
To collect
subjective data
. Which is what the person says about himself or herself.
By combining this subjective data with objective data from the PE & diagnostic tests, you create a database to make a judgment about the person's health status.
No matter what form is used to record the health history, plan to gather data in 8 categories
1. Biographical data
2. Source of history
3. Reason for seeking care
4. Present health history/ illness
5. Past health info
6. Family history
7. Review of systems
8. Cultural/ADLs
Taking an older adult's health history
Ask additional questions. For example, explore changes in activities of daily living that may result from aging process or chronic illness. Remember the impact or burden of a disease may be more important to an older adult rather than the actual disease,
To determine patients perception of pain
Nurse would determine the meaning of the symptom by asking how it affects ADLs & what the pt thinks the pain means. Known pt's culture it can also influence their pain tolerance.
CAGE screening questionnaire
C=Cut down, A=Annoyed, G=guilty, E=eye opener
The reason for seeking care
a statement in the person's own words that describes the reason for the visit. Replaced "chief of care" to incorporate wellness needs
Presence or Absence of symptoms list
P=provocative or palliative
Q=quality or quantity
R=region or radiation
S=severity scale
T=timing
U=understanding patient's perception
Reliable person
will always give same answers, even when questions are rephrased or repeated later in the interview
Adolescent interview
Should be with youth alone; the parent(s) may wait in the waiting area & complete other past health questionnaire forms