HEALTH HISTORY

 Comprehensive record of the patient’s past and current health

 Gives subjective information on how a health condition came about
 Data Information to be gathered:
o Level of Wellness
o Changes in Life Patterns
o Socio-cultural Role
o Mental and Emotional Reactions to Illness
o Other Health Condition

Database Sources:
1. Health History
2. Physical Assessment
3. Laboratory and Diagnostic Tests
4. Materials Contributed by Other Health Personnel

Purpose:
 Identify:
o Patterns of Health and Illness
o Risks Factors for Health Problems
o Deviations from Normal
o Available Resources for Adaptation

Guidelines in History Taking

1. Sources of Information
Primary Source – Client
Secondary Source – Family or Significant Others, Health Team Members and Client’s Health Record
2. Most of the Data are Subjective
3. Focus on data or information from all the client’s dimension
4. Record data using clear, concise and appropriate terminology

Interview (Health Hx)

 Means of collecting subjective data
 A formal, planned interaction to inquire about:
 Patient’s health problem/pattern
 ADLs
 Past Health Hx
 Current Health Issues
 Self-care Activities
 Wellness Concerns

Focus of Interview
1. Establishing rapport and trusting relationship with the client
2. Gathering information on the client’s developmental, psychological, physiologic, socio-cultural and
spiritual statuses.
Phases of the Health Assessment Interview
1. Pre-interaction
 Collection of data from medical record, previous health risk appraisal, health screenings,
therapists and other health care professionals.
 Information obtained during the phase plan and guide the direction of initial interview
 Nurse reflects on his or her own strengths and limitations
2. Initial Interview
 Gathering information from the patient
 Use of Health History Form
 Establishing NPR
 Explaining the importance of the interview, telling what to expect
3. Focused Interview
 Clarify previously obtained assessment data
 Gather missing information about a specific health concern
 Update and identify new diagnostic cues as they occur
 Guide the direction of physical assessment
 Identify or validate probable nursing diagnosis

Guidelines of an Effective Interview

1. Start by using icebreakers
2. Be observant
3. Ask questions in a non-threatening way
4. Let the interview flow naturally
5. Obtain cues about which part of the data collected requires in-depth investigation
6. Control the interview

Approaches to Interview
1. Directive (Closed)
 Highly structured
 Elicits specific information
 Nurse controls subject matter
 Used when time is limited
2. Non-Directive (Open-Ended)
 Nurse allow the patient to control the purpose, subject matter and pacing of the interview

Types of Interview Questions

1. Closed
 Generally require yes or no or short factual answers giving specific information
2. Open-Ended
 Specific broad topics to be discussed and invite longer answers
3. Neutral
 Can be answered by the client without direction or pressure from the nurse
4. Leading
 Direct the client’s answer