Health History

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					Health History


  Purpose:
  To obtain information about a client’s
  health status in an organized & orderly
  form
   Generally gathered by the primary care
    provider

   Be careful to avoid misspelling, transcription
    errors, or misinformation in the patient’s
    record or chart – it is a legal document!
   Avoid transcribing subjective, patient-based
    info in anything other than quotation marks
Health History may be used:

   To provide continuity of care
   It is a legal document & may be used in a
    legal suit
   Information may also be used in insurance
    claims
Who provides the history:

   Primary source – client
   Secondary source – family / caregiver /
    friends / significant others / records
   Note special circumstances – use of an
    interpreter
   Be sure to record the history data precisely,
    with sufficient details, avoiding vague
    statements such as lots or little
Patient Profile
   Demographic/Biographical date - objective &
    broadly inclusive of who the patient is…
       Name
       Age
       Sex
       Race or ethnic heritage
       Martial status
       Religion
       Occupation
       Diagnosis or presenting problem
   Name: identifies the patient.
       Clarifies who you are describing, personalizes the
        report, keep the patient from being thought of as a
        disease.
   Be respectful!

   Age:
       Permits you to begin evaluating the individual’s
        characteristics in relation to expectations of
        physical & social characteristics across the life
        span
   Will also guide your health teaching
   Gender:
       There are differences according to gender in
        terms of physical development & reproduction


   Race/Ethnicity:
       Adds info necessary for risk assessment & health
        teaching. Needed in screening & in prescribing
        medications


   Marital Status:
       Info about patient’s support system (physical &
        emotional) & responsibilities that may be affected
        by hospital confinement
   Religion:
       Religious beliefs often influence perceptions about
        health & illness


   Employment Status:
       Patient’s responsibilities that will be affected as
        well as his ability to pay for care

 Referral Source:
     Where to access current health info
Reason for Referral/Chief Compliant
   Enter in quotation marks
   It is a subjective element given by the person & is
    not usually amended by the interviewer
   Ie. “I might have TB”

   Examples:
       Decreased visual acuity
       “I feel like I am looking through a dirty window”

       “I have a cold & my nose is stuffy”
       Upper respiratory infection
History of Present Illness

   Investigate the reason for seeking care
   If the problem started months ago, ask them
    why they are seeking care now
   Investigate the location, the character or
    quality, the quantity or how severe, when did
    it first appear, any other symptoms, etc
   PQRST
Current Health Problems

   A chronological listing of ongoing health
    issues, not necessarily related to patient’s
    current compliant

   For a well person, this is usually a short list
Past Health History

   All known health related events in the
    patients life from birth to present

   Illness, accidents, surgery, immunizations,
    allergies, meds, dental, eye, risk factors
    (international travel, transfusions), childhood
    illness (measles, chicken pox), chronic illness
    (HTN, diabetes), operations, last examination
    date
Family History

   Ask about age & health or age & cause of
    death of blood relatives (parents,
    grandparents, siblings)

   Ie. negative for HTN, CVD, obesity, diabetes,
    TB, renal disease, psychiatric problems
Occupational/Employment History


   Their work history, military service, potential
    past/current exposures, injuries
Personal/Social History

   Family/cultural influences
   Education
   Martial/relationship history
   Current life situation
Review of Systems

   NOT a physical assessment – it is the
    subjective data collected prior to the objective
    physical assessment
   A logical head to toe overview of what the
    patient reports about his/her health during the
    interview
   Will cover in more detail as we address each
    system in class
Verbal Report

   Short, one minute or less, review of patient’s
    history. May include facts from a physical
    exam if one was done
Patient Summary

   Counterpart to verbal report
   Found at the end of health history.
   Brief overview of pertinent details of patient
In completing Orem’s Assessment:

   USCR (air, food, fluid, elimination, activity,
    social interaction, prevention from hazards,
    normalcy)
   HDSCR (assistance from health care system,
    pathological condition, treatment measures)
   DSCR (maturational, situational)
   Identify the nursing system (wholly
    compensatory, partially compensatory,
    educative/supportive)
Cultural & Social Considerations
in Health Assessment
Culture

   Culture is an inherently complex dimension of
    peoples’ lives
   Because health care in Canada has drawn on
    narrowly defined ideas about culture, many
    nursing texts provide lists of cultural
    characteristics for various groups.
   While some of these characteristics are
    applicable to some people, they certainly do
    not apply to all members of a group.
   Applying lists of cultural traits to patients you
    encounter leads to stereotypes & making
    assumptions about particular people, which
    will lead to unsafe health assessment
    practices.
   HCP must find ways to learn about their
    patients, and their context, to understand how
    best to address their health needs
Cultural Sensitivity


    HCP should be sensitive to people’s
    values, beliefs, customs, & practices
Health, Social & Gender Inequities
   Particular groups of people experience
    especially high rates of ill health because of
    social, economic, & historical conditions
   People living in poverty, lone mothers in low-
    income brackets, older women, people who
    experience discrimination or racism,
    significant proportions of Aboriginal
    population, people with severe or persistent
    mental illnesses or addictions are more likely
    than others to become ill and less likely to
    receive appropriate healthcare services
Guidelines for Clinical Practice
   Performing a health assessment proceeds
    over time.
   Patients should not be expected to share
    sensitive information until trust has been
    established
   Patients may be reluctant to reveal their
    beliefs for fear of being dismissed
   Phrase questions in an open nonjudgmental
    way – “have you found anything else that has
    helped you?”
   Engaging in conversations with patients or
    their family during the process of establishing
    trust will help you gain a deeper
    understanding of their health, illness, and
    approaches to healing
   Building trust, engaging through listening,
    conveying respect for differences, and paying
    attention to the context of people’s lives are
    key to culturally safe health assessments.

				
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posted:12/12/2011
language:English
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