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
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

What can the biographical data tell you?
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 = Precipitating / palliative factors
Q = Quality / quantity of symptom
R = Region / radiation / related symptoms
S = Severity
T = Timing
Past Health History
Hospitalizations
Serious injuries
Allergies
Transfusions
Military service
Surgeries
Immunizations
Medications
Recent travel
Childhood illnesses
What can the past health history tell you?
Family History
What can the family history tell you?
Patient
Children
Siblings
Grandparents
Spouse
Parents
Aunts and uncles
Review of Systems
General health status
Endocrine
Genitourinary
Reproductive
Musculoskeletal
Neurological
Immune
Hematological
Integumentary
HEENT
Respiratory
Cardiovascular
Breasts
Gastrointestinal
What can the review of systems tell you?
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
Typical day
Activity & exercise
Sleep/rest patterns
Personal habits
Health practices & beliefs
Occupational health
patterns
Socioeconomic status
Environmental health
patterns
Role, relationships, self-
concept
Cultural influences
Religious/spiritual
influences
Nutritional patterns
Recreation, pets, hobbies
What can the psychosocial history tell you?
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.