CHAPTER 2:

The Health History

After you have successfully completed this
chapter, you should be able to:
■ Discuss purpose of the health history
■ Define the components of the health
history
■ Differentiate between a complete vs.
focused health history
■ Differentiate a nursing health history
from a medical health history
■ Identify the key questions for a symptom
analysis
■ Obtain a health history
■ Document your health history
PURPOSE OF THE
HEALTH HISTORY
 Purpose of the Health History
1. Provide the subjective database.
2. Identify patient strengths.
3. Identify patient health problems,
both actual and potential.
4. Identify supports.
5. Identify teaching needs.
6. Identify discharge needs. Identify referral
needs.
TYPES OF
HEALTH
HISTORIES
Types of Health Histories
1. Complete health history
— includes biographical data, reason for
seeking care, current health status, past
health status, family history, a detailed review
of systems, and a psychosocial profile.

2. Focused health history

} focuses on an acute problem, so all of your
questions will relate to that problem.
 2. Focus health history
— A focused health history contains
necessary biographical data, including
the patient’s name, age, birth date,
birthplace, gender, marital status,
dependents, race, religion, address,
education, occupation, contact person,
and health insurance/social security
number.
— It also includes the source of the health
history and her or his reliability, who
referred the patient, and whether or not
the patient has an advance directive.
FOCUSED VERSUS
COMPREHENSIVE
HISTORY
 Focused versus Comprehensive
History

1.Patient’s Condition
— First, determine the condition of your patient.
This condition may prohibit a detailed health
history upon admission.
2. Amount of Time
} Allot at least 30 minutes to an hour to obtain
a complete health history.
} Be sure to let your patient know why you are
asking these questions and that it will take
time.
MEDICAL HISTORY
VERSUS
NURSING HISTORY
 Medical History versus
Nursing History
— The areas addressed and the
questions asked during a medical
health history are very similar to
those in a nursing health history.
— However, some important
differences exist. These
differences are defined by the
focus and scope of medical versus
nursing practice.
 Setting the Scene
— Before you begin your assessment, look
at your surroundings.
— Do you have a quiet environment that is
free of interruptions?
— Make sure that the patient is comfortable
and that the room is warm and well lit.
— If the patient uses assistant devices,
such as glasses or a hearing aid, be sure
that she or he uses them during the
assessment to avoid any misperceptions.
Setting the Scene
— Before you begin asking questions, tell
your patient what you will be doing and
why.
— Inform him or her if you will be taking
notes, and reassure the patient that
what he or she says will be confidential
— Be sure to work at the same level as
your patient. Sit across or next to her or
him.
COMPONENTS OF THE
HEALTH HISTORY
The parts of the health history
A. The biographical data
B. Reason for seeking
healthcare
C. Current health status
D. Past health history
E. Family history
F. And review of systems.
REASON FOR SEEKING
HEALTHCARE
 b. Reason for Seeking Healthcare
— If there is an acute problem, ask the
patient to state what the problem is and
how long it has been going on.
— For example, “I have had chest pain for
the last hour.”
— In an acute-care setting, the reason for
seeking care is called the chief complaint.
— The chief complaint gives you the
patient’s perspective on the problem, a
view of the problem through his or her
eyes.
C. CURRENT HEALTH
STATUS
 Current Health Status
— At a primary level of healthcare (no
acute problem), the current health
status should include the following:
■ Usual state of health.
■ Any major health problems.
■ Usual patterns of healthcare.
■ Any health concerns.
— Perform a symptom analysis for any
positive symptom that your patient
reports.
The helpful mnemonic PQRST provides
key questions that will give you a good
overview of any symptom.

Precipitating/Palliative Factors
— Ask: What were you doing when
the problem started?
— Does anything make it better,
such as medications or certain
positions? Does anything make it
worse, such as movement
— or breathing?
The helpful mnemonic PQRST provides key questions
that will give you a good overview of any symptom.

■ Quality/Quantity
Ask: Can you describe the
symptom? What does it feel like,
look like, or sound like?
How often are you experiencing it?
To what degree does this problem
affect your ability to perform your
usual daily activities?
The helpful mnemonic PQRST provides key questions
that will give you a good overview of any symptom.

■ Severity
Ask: Is the symptom mild,
moderate, or severe?
Grade it on a scale of 0 to 10, with
0 being no symptom and 10 being
the most severe. (Grading on a scale
helps
objectify the symptom.)
 The helpful mnemonic PQRST provides key
questions that will give you a good overview of
any symptom.
■ Timing
Ask: When did the symptom
start? How often does it occur?
How long does it last?
D. PAST HEALTH
HISTORY
 Past Health History
— The past health history assesses
childhood illnesses, hospitalizations,
surgeries, serious injuries, adult
medical problems (including serious
or chronic illnesses), immunizations,
allergies, medications, recent travel,
and military service.

— The purpose is to identify any health

factors
from the past that may have a direct
relationship to your patient’s current
health status.
E. FAMILY HISTORY
 Family History
— The family history provides
clues to genetically linked or
familial diseases that may be
risk factors for your patient.
— Ask about the health status
and ages of your patient’s
family members.
Family History
— Ask about genetically linked or
common diseases, such as heart
disease, high blood pressure,
stroke, diabetes, cancer, obesity,
bleeding disorders, tuberculosis,
renal disease, seizures, or mental
disease. If the patient’s family
members are deceased, record the
age and cause of death.
 Family History
— The family history may be recorded in
one of two ways.
◦ List family members along with their
age and health status
◦ GENOGRAM (family tree)- allows you
to identify familial risk factors at a
glance. When developing a genogram,
use symbols to represent family
members, and include a key to explain
the symbols and abbreviations.
◦ Ecomap
F. REVIEW OF SYSTEMS
Review of Systems
} The review of systems (ROS) is a
litany of questions specific to each body
system.
} The questions are usually about the
most frequently occurring symptoms
related to a specific system.
} The ROS is used to obtain the current
and past health status of each system
and to identify health problems that
your patient may have failed to mention
previously.
Psychosocial Profile
Psychosocial Profile
— last section of the health history.
— This section focuses on health
promotion, protective patterns,
and roles and relationships.
 Psychosocial Profile
— It includes questions
◦ Healthcare practices and beliefs
◦ A description of a typical day
◦ A nutritional assessment
◦ Activity and exercise patterns
◦ Recreational activities
◦ Sleep/rest patterns
◦ Personal habits
◦ Occupational risks
◦ Environmental risks,
◦ Family roles and relationships
◦ Stress and coping mechanisms.
Documenting Your Findings
Documenting Your Findings
— Summarize pertinent findings and share
them with your patient to confirm their
accuracy.
— here are some helpful hints for
documenting a health history:
■ Be accurate and objective. Avoid stating
opinions that might bias the reader.
■ Do not write in complete sentences. Be brief
and to the point.
■ Use standard medical abbreviations.
■ Don’t use the word “normal.” It leaves too
much room for interpretation.
■ Record pertinent negatives.
■ Be sure to date and sign your