Introduction:

The health history provides the subjective database for your assessment, allowing you to interact with your patient. It consists of what the patient tells you, what the patient perceives, and what the patient thinks is important. It provides a holistic, qualitative picture of your patient. Data that you obtain from the health history will direct your physical assessment and are essential in developing a successful plan of care for your patient.

 

Topic Learning Outcome (TLOs):

By the end of this topic, you should be able to:

1. Discuss purpose of the health history.
2. Differentiate between a complete and focused health history
3. Differentiate a nursing health history from a medical health history
4. Identify the components of the complete health history.
5. Document health history.

Purpose of the Health History

The purpose of the health history is to identify not only actual or potential health problems but also your patient’s strengths. It should also identify discharge needs. In fact, a successful discharge plan begins on admission with the health history. To create a successful plan of care, you must take a holistic view of your patient and all that affects her or him. Remember: The plan you develop will be successful only if your patient is able to follow through with it after discharge. In summary, the purpose of the health history is to:

·         Provide the subjective database.

·         Identify patient strengths.

·         Identify patient health problems, both actual and potential.

·         Identify supports.

·         Identify teaching needs.

·         Identify discharge needs.

·         Identify referral needs.

Types of the Health History

A health history may be either complete or focused. A 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. A focused health history focuses on an acute problem, so all of your questions will relate to that problem.

Complete Health History

The complete health history begins with biographical data, including the patient’s name, age, gender, birth date, birthplace, marital status, race, religion, address, education, occupation, contact person, and health insurance/social security number. It should also include the source of the health history and his or her reliability, who referred the patient, and whether or not the patient has an advance directive. Once you have obtained this information, you should then identify the reason for seeking healthcare, followed by a description of current health status.

 

The past health history includes childhood illnesses, surgeries, injuries, hospitalizations, adult medical problems, medications, allergies, immunizations, travel, and military service. The family history will identify familial or genetically linked disorders. The review of systems provides a comprehensive assessment to determine your patient’s physiological status. Past or current problems may be identified and warrant further investigation.

 

The psychosocial profile gives you a picture of your patient’s health promotion and preventive patterns. It includes a description of health practices and health beliefs, a typical day, nutritional patterns, activity/exercise patterns, recreational patterns, sleep/rest patterns, personal habits, occupational and environmental risk factors, socioeconomic status, developmental level, roles and relationships, self-concept, religious and cultural influences,

supports, sexuality patterns, and finally, the emotional health status of your patient. Once you have completed the health history, summarize any pertinent data.

 

A complete health history provides a comprehensive, holistic picture of your patient. It screens for actual or potential problems and identifies your patient’s strengths and health promotion patterns. A complete health history may be obtained in a primary setting as a screening tool, in a secondary setting once your patient’s condition stabilizes, or in a tertiary setting to establish a baseline from which to develop your plan of care.

Focused 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. You should then identify the reason for seeking care, followed by a complete symptom analysis.

 

In your past health history, address any areas that relate to the reason for seeking care, including diseases of high incidence in the United States, such as heart disease, hypertension, cancer, diabetes, and alcoholism. In your review of systems, ask questions about every system and how it relates to the presenting health problem. The questions in the psychosocial profile identify the impact of the presenting health problem on your patient’s life.

 

A focused health history may be indicated when your patient’s condition is unstable or when time constraints are an issue. Focused health histories may also be used for episodic follow-up visits for your patient. In this case, you have already obtained a detailed health history at

an earlier point and have established the subjective database. During the follow-up visits, you need to obtain further subjective data to monitor and evaluate your patient’s progress. Once you have completed the focused health history, remember to document any pertinent findings.

Focused versus Comprehensive History

Deciding which type of health history to do depends on two factors: your patient’s condition and the amount of time you have.

 

Patient’s Condition:

First, determine the condition of your patient. This condition may prohibit a detailed health history upon admission.

For example, if you are working in the emergency department and Mr. Rahim, a 49-year-old man, presents with acute chest pain, a comprehensive health history is not indicated. Instead, you should obtain a focused history while you perform a physical assessment, draw

laboratory studies, obtain an electrocardiogram, and connect your patient to a cardiac monitor. When a patient is in acute distress, trying to obtain a complete health history

not only is detrimental but also provides little valuable or accurate information. So, ask key questions that focus on the acute problem; once your patient’s condition stabilizes, obtain a more detailed health history.

 

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. If you do not have enough time to complete the history, do not rush. Instead, perform a focused history first, and then complete the history at later sessions.

FORUM:

·         Suppose you were caring for Mr. Rahim. What questions would you ask him to assess his chest pain?

·         What question(s) would you ask Mr. Rahim related to his past health history, family history, review of systems, and psychosocial profile?

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. Although the history questions are similar, the underlying rationale differs. Remember: Physicians diagnose and treat illness. Nurses diagnose and treat the patient’s response to a health problem.

 

For example, Janushree, an 81-year-old woman, is admitted to the hospital with a fractured right hip. The focus of the medical history would be to identify what caused the fracture in order to determine the extent of injury. The history would also try to identify any pre-existing medical problems that might make her a poor surgical risk. The physician will use the data that he or she obtains to develop a treatment plan for the fracture.

 

Although the nursing health history also focuses on the cause of the injury, the purpose is to determine Mary Johnson’s response to the injury, or what effect it has on her. You will look at much more than the fractured hip. You will consider how the injury affects every aspect of her health and life. Your history will provide clues about the impact of the injury on her ability to perform her everyday activities and help you identify strengths she has that can be incorporated into her plan of care. You will also identify supports and begin your discharge plan. Then you will use the data to develop a care plan with Mary Johnson that includes not only her perioperative phase but also her discharge rehabilitative planning.

Setting the Scene

Before you begin your assessment, look at your surroundings. Do you have a quiet environment that is free of interruptions? A private room is preferred, but if one is

not available, provide privacy by using curtains or screens. Prevent interruptions and distractions so that both you and your patient can stay focused on the history. 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.

 

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. However, avoid excessive note taking—it sends the message to your patient that the health history form is more important than he or she is. Also, if you are too preoccupied with writing and continually break eye contact, you may miss valuable nonverbal messages. Excessive note taking may also inhibit your patient’s responses, especially when discussing personal and sensitive issues such as sexuality or drug or alcohol use.

 

Be sure to work at the same level as your patient. Sit across or next to her or him. Avoid anything that may break the flow of the interview. If the interview is being recorded or videotaped, be sure to get your patient’s permission before starting. Position the equipment as unobtrusively as possible so that it does not distract you or your patient.

 

Your approach to your patient depends on his or her cultural background, age, and developmental level.

FORUM:

·         Ask yourself, “Are there any cultural considerations that might influence our interaction with patient?”

·         “What approach is best, considering my patient’s age?”

Let COMPARE the following TWO video clip (VIDEO 1 & VIDEO 2) of Nurse-patient Interview:

Video:1

Video: 2

 

Nurse-Patient Interview

Reflection questions:

1. Describe your observations of the interview as seen in the above video. 

2. What will you do differently to improve the nurse -patient interview?

3. Name one lesson learned that you will apply in patient care?

QUIZ:

The nurse will obtain a health history of a patient who is admitted to a care unit. Which patient condition will require the nurse to consider secondary source of data?

1. patient is currently confused
2. patient is alert but mute
3. patient's partner offers to provide information

Components of the Health History

A complete health history addresses health and illness patterns, health promotion and protective patterns, and roles and relationships. The parts of the health history that focus on health and illness patterns include the biographical data, reason for seeking healthcare, current health status, past health history, family history, and review of systems. You identify not only current health problems but also past health problems and any familial factors that place your patient at risk for health problems. Your patient’s health promotion activities, protective patterns, and role and relationship patterns are assessed through the psychosocial component of the health history. Here, you assess for risk factors that pose a threat to your patient’s health in every aspect of her or his life. Also, you need to consider your patient’s cultural and developmental status as it affects her or his health status. Here are the components in nursing health history:

1. Biographical data:

The biographical data provide you with direct information related to a current health problem, alert you to risk factors for health problems, and point out the need for referrals. Your patient’s ability to provide biographical data accurately reflects his or her mental status.

Biographical data include the patient’s name, address, phone number, contact person, age/birth date, place of birth, gender, race, religion, marital status, educational level, occupation, and social security number/ health insurance. They also include the person who provided the history and her or his reliability as well as the person who referred the patient. Information on advance directives may also be obtained for hospital admissions. Also note any special considerations, such as the use of an interpreter.

 

II.   Reason for Seeking Healthcare

Ask your patient why he or she is seeking healthcare; then document his or her direct quote. The patient’s reason for seeking care is usually related to the level of preventive healthcare —primary, secondary, or tertiary. If the setting is a primary level of healthcare, there is usually no acute problem. The reason generally relates to health maintenance or promotion. For example, the patient states, “I am here for my annual physical examination.”

 

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.” If your patient identifies more than one problem, she or he may be confusing associated symptoms with the primary problem. Help her or him clarify and prioritize the problems by asking questions such as, “Which problems are giving you the most difficulty?”

 

Usually, patients identify problems that affect their ability to do what they usually do. 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.

 

At the tertiary level, the problem may be well defined, a chronic problem, or an acute problem that is resolving. In this case, the problem does not have the acuity or life-threatening urgency of an acute problem.

 

3. Description of Current Health Status / Present Health History

Assess her or his 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.

 

 

For example: Patient is Mary, age 42, married, mother of three, full-time teacher. Usual state of health good. Has yearly physical with pelvic examination and dental examination. Last eye examination 1 year ago. Expresses concern regarding family history of hypertension and ovarian cancer.

 

 

Patients in secondary or tertiary healthcare settings have an existing problem. So, you will need to perform a symptom analysis to assess your patient’s presenting symptoms thoroughly. Although many questions come to mind, your patient’s condition and time constraints may preclude you from going into too much detail. If so, you’ll need to zero in on several key areas to evaluate your patient’s symptoms. As you perform the symptom analysis, try to determine how disabling this problem is for your patient. Also ask if he or she has any medical problems related to the current problems and if he or she is taking any medications for this current problem.

 

The helpful mnemonic PQRST provides key questions that will give you a good overview of any symptom. Although you can ask additional questions, the following ones provide a thorough analysis of any presenting symptom:

 

P- 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?

 

Q- 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?

 

R- Region/Radiation/Related Symptoms

Ask:

Can you point to where the problem is?

Does it occur or spread anywhere else? (Take care not to lead your patient.)

Do you have any other symptoms? (Depending on the chief complaint, ask about related

symptoms. For example, if the patient has chest pain, ask if she or he has breathing problems or nausea.)

 

S- Severity

Ask:

 Is the symptom mild, moderate, or severe?

Grade it on a pain scale of 0 to 10, with 0 being no symptom and 10 being the most severe. (Grading on a scale helps objectify the symptom.)

 

T- Timing

Ask:

When did the symptom start?

How often does it occur?

How long does it last?

 

 

IV.     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. For example, a history of rheumatic fever as a child may explain mitral valve disease as an adult.

 

 

The past health history also identifies any chronic pre-existing health problems, such as diabetes or hypertension, which may directly affect the current health problem. For example, patients with diabetes often have poor wound healing. Also, even though the chronic disease

may be well controlled, the current health problem may cause an exacerbation. For instance, a patient with well-controlled diabetes may need to adjust his or her medication when scheduled for surgery, because the stress of surgery can elevate blood glucose. In addition, the past health history can identify additional health risks caused by pre-existing conditions.

 

 

The past health history may also explain your patient’s response to illness, healthcare, and healthcare workers. If she or he has a history of multiple medical problems requiring frequent hospitalizations, these experiences may affect her or his perception of healthcare either positively or negatively.

 

 

When obtaining the past health history, be sure to ask for dates, physicians’ names, names of hospitals, and reasons for hospitalizations or surgeries. This information is important if past records are needed. Also avoid using terms such as “usual,” general,” or “routine.” For example, “usual” childhood illnesses vary depending on the age of your patient and available immunizations.

 

V.  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 members include the patient, spouse, children, parents, siblings, aunts and uncles, and grandparents. 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.

 

 

The family history may be recorded in one of two ways. You can list family members along with their age and health status, or you can use a genogram (family tree). A genogram 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.

FORUM:

·         After studying the boxed family history on page 35, what familial health risks would you identify for this patient?

VI. 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. Remember, if your patient has an acute problem in one area, every other body system will be affected, so look for correlations as you proceed with the ROS. Then perform a symptom analysis for every positive finding and determine the effect of, and the patient’s response to, this symptom. The ROS also provides clues to health promotion activities for each particular system. Identify health promotion activities and provide instruction as needed.

VII.   Psychosocial Profile

The psychosocial profile is the last section of the health history. This section focuses on health promotion, protective patterns, and roles and relationships. It includes questions

about 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 and stress and coping mechanisms.

 

In a primary healthcare setting, the psychosocial assessment enables you to identify how your patient incorporates health practices into every aspect of her or his life. You can then teach and reinforce health promotion activities that your patient can incorporate into her or his everyday life. If she or he has an acute problem, the psychosocial assessment helps you determine the impact of this illness on every facet of the patient’s life and assists you in determining discharge planning needs. For your plan of care to be successful, the patient must be able to follow through with it after discharge. Help ensure success by identifying clues as you perform the assessment and then making appropriate referrals.

 

8.    Developmental considerations

A person’s development crosses the life span. Developmental assessments are often performed on children because the developmental changes that occur at this age are very observable and measurable. Yet adults also go through developmental changes that you need to consider during the assessment. Illness and hospitalization can have a major impact on a child’s growth and development, by either halting its progression or regressing it to an earlier stage.

For example, when Johnny, age 4, is admitted to the hospital for a hernia repair, he begins

wetting the bed during the night, even though his mother assures you that he has been “potty trained” since age 3.

 

 

Documenting Your Findings

 

Once you have completed the health history, summarize pertinent findings and share them with your patient to confirm their accuracy. Then document your findings and begin to formulate a plan of care.

 

 

Documentation of history findings varies from one healthcare facility to another. Many acute-care facilities use computerized programs that enable you to enter the history directly into the computer. Standardized nursing admission assessment forms that combine both history and physical assessments are also commonly used.

 

Regardless of the system, 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 documentation.

For further understanding, let watch the following Video clip on “Charting for Nurses | How to Understand a Patient's Chart as a Nursing Student or New Nurse”:

QUIZ:

1. The nurse is completing documentation via the DAR notes. What does each initial of DAR stand for?

A.   A is for all nursing actions  

B.   A is for assessment findings

C.   R is for the nurse’s reaction to the assessment findings

D.   R is for patient’s response to nursing interventions  

D is for deficient knowledge

2. The nurse is using the documentation style whereby only abnormal findings are documented. What is this style of documentation called?

A.   Discharge teaching note.

B.   Narrative note.

C.   SOAPIE note.  

D.   By exemption note

Summary:

 

The health history provides the subjective database for your patient’s assessment. It is usually your first major interaction with your patient and often provides the foundation of your nurse-patient relationship.

Here I would like to end this topic with a Video clip “Master clinical history taking (with patient example)”: