The Health History

Purposes
Provides subjective
data base
Identifies patients
strengths
Identifies patients
actual and potential
health problems
Identifies support
systems

Identifies learning
needs
Identifies discharge
needs
Identifies referral needs

Types of Health History

Complete provides a
comprehensive, holistic picture of your
pt

Past Health History includes:

childhood illness

surgeries

injuries

hospitalization

adult medical problems

medications

allergies

immunizations

travel

military services

Psychosocial profile gives you a

picture of your pt's health promotion
and preventive patterns.

Includes:
description of health practices
health belief
nutritional patterns
activity/exercises
recreation
sleep/rest
personal habits
occupational risk factors
environmental risk factors
socioeconomic status
sexuality

Types of Health History

Focused
may be indicated when your patient's condition
is unstable or when time constrain are an issue.
- contains necessary biographical data
-

Medical versus Nursing

History
How does a medical history differ from
nursing?
Medical
Focuses on diagnosis and treatment of
illness
Nursing
Focuses on diagnosis and treatment of
human responses to health problems

Components of the
Health History

Biographical data
Current health status
Past health history
Family history
Review of systems
Psychosocial history

Biographical Data
What can the biographical data tell you?

Name
Address & phone
Contact
Age, birth date
Gender
Social Security number
Referral source
Source of history and
reliability

Race/ethnicity
Religion
Marital status
Education
Occupation
Insurance
Advanced directives

Current Health Status

What can the patients reasons for seeking
health
care and the patients current health status tell
you?
Primary Level of Health Care usual state of
health, major health problems, usual patterns
of care, and any health concerns
Secondary or Tertiary Levels of Health Care
perform a symptom analysis

Symptom Analysis
P
Q
R
S
T

=
=
=
=
=

Precipitating / palliative factors

Quality / quantity of symptom
Region / radiation / related symptoms
Severity
Timing

Past Health History

What can the past health history tell you?

Hospitalizations
Serious injuries
Allergies
Transfusions
Military service

Surgeries
Immunizations
Medications
Recent travel
Childhood illnesses

Family History
What can the family history tell you?
Patient
Children
Siblings
Grandparents
Spouse
Parents
Aunts and uncles

Review of Systems
What can the review of systems tell you?

General health status

Endocrine
Genitourinary
Reproductive
Musculoskeletal
Neurological
Immune

Hematological
Integumentary
HEENT
Respiratory
Cardiovascular
Breasts
Gastrointestinal

Developmental
Considerations
Consider:
Past developmental stages
Current developmental stages

Developmental Theories

Freud
Erikson
Maslow
Piaget
Kohlberg
Gilligan

Peck
Havighurst
Cumming & Henry
Duvall
Butler

Psychosocial History
What can the psychosocial history tell you?
Typical day
Activity & exercise
Sleep/rest patterns
Personal habits
Health practices & beliefs
Occupational health
patterns
Socioeconomic status

Environmental health
patterns
Role, relationships, selfconcept
Cultural influences
Religious/spiritual
influences
Nutritional patterns
Recreation, pets, hobbies

Documentation

Be accurate and objective.

Be brief and to-the-point.
Document in short phrases.
Use standard medical abbreviations.
Avoid normal, usual, general.
Record pertinent negatives.
Date and sign documentation.