30 Questions
What is the main purpose of collecting health history?
To combine with objective data to form a complete picture of patient's health status
What is the sequence of obtaining information in a health history?
Biographic data, source of history, reason for seeking care
What is included in the review of systems?
Functional assessment including activities of daily living (ADLs)
Why may the focus of a health history differ?
Depending on the clinical practice setting and/or nature of complaint
What is an area of focus in a health history?
Developmental considerations
What is a health history used for?
As a screening tool for detection of abnormalities
What is the primary focus of obtaining a patient's past medical history?
To obtain specific pertinent information for better clinical decision making
Which of the following options is considered a well-described clinical symptom?
A clinical symptom with precipitating and alleviating factors
What is the impact of comorbidities on a patient's health status?
It has a pronounced effect on present and future health
What information should be obtained when documenting a patient's hospitalizations?
The type and nature of the event, acute and/or residual deficit noted, and dates of occurrences
Why is it essential to obtain detailed information about a patient's past medical history?
To provide cues for better clinical decision making
What is included in the documentation of a patient's operations?
The facility, name of healthcare provider, and date of procedures
What is the primary purpose of obtaining a family history?
To determine the risk of genetic diseases
What is the purpose of including biographic data in cross-cultural care?
To determine the patient's spiritual resources and religion
What is the purpose of correlating allergies with CDC Guidelines?
To ensure proper immunization administration
What is the primary purpose of a pedigree or genogram in family history?
To standardize the collection of family history data
What is included in the assessment of prenatal, perinatal, and postnatal status?
childhood illnesses and potential complications
What is the purpose of including the postpartum course in obstetric history?
To provide relevant information about childbearing experiences
What is the purpose of performing medication reconciliation?
To ensure that all prescribed and over-the-counter medications are accounted for
What is the purpose of documenting the reason for care and hospital facility location?
to obtain information about operations or hospitalizations
What is included in the assessment of childhood illnesses?
age of occurrence, types of illness, and potential complications
What is the purpose of documenting immunizations per CDC recommendations?
to ensure adherence to established guidelines
What is included in the assessment of medications?
dosage, schedule, and clinical indication
What is the purpose of documenting growth and developmental milestones?
to assess and reassess growth and developmental achievements across life cycle
When conducting a health history for an infant, what aspect of nutrition is particularly important to consider?
Breast or bottle-feeding as a source of nutrition
What is the primary goal of a review of systems for a child?
To focus on specific body systems and health promotion
When conducting a functional assessment for a child, what aspect of daily life is particularly important to consider?
ADLs and their relation to the child and family unit
What is the primary consideration when assessing the general health state of a child?
Cognitive and developmental age-appropriate behaviors
What is the benefit of including at least two individuals in a health history, such as a parent and/or child?
To obtain more accurate information about the child's health
What is the primary focus of a health history for a child?
Focusing on specific body systems and health promotion
Study Notes
Health History
- Collects subjective data to combine with objective data from physical exam and lab studies to form the database.
- Provides a complete picture of patient's past and present health status.
- Can be used as a screening tool for detection of abnormalities.
Health History Sequence
- Biographic data
- Source of history
- Reason for seeking care
- Present health or history of present illness
- Past health
- Family history
- Review of systems
- Functional assessment including activities of daily living (ADLs)
Past Medical History
- Focus on obtaining specific pertinent information relative to each of the identified categories.
- More accurate and detailed information obtained leads to better clinical decision making.
- Provides cues as to how patient's cope with illness and/or health concerns.
Past Medical History Categories
- Childhood illnesses
- Accidents or injuries
- Presence of comorbidities
- Hospitalizations
- Serious or chronic illnesses
- Operations
- Obstetric History
- Immunizations
- Allergies
- Last Examination Date
- Current Medications
Family History
- Highlights diseases or conditions that an individual may be at risk for as a result of genetics.
- Provides age and health or cause of death of relatives.
- Ability based on results to seek early screening, make possible lifestyle adjustments, and/or undergo periodic surveillance.
- Pedigree or genogram used as standardized tool to organize data.
Functional Assessment: Child
- Focus on ADLs and how they relate to the child and family unit.
- Interpersonal relationships
- Activity and rest
- Economic status
- Home environment
- Environmental hazards
- Coping and stress management
- Habits
- Health promotion
This quiz covers the purpose and importance of collecting subjective data through a complete health history, combining it with objective data from physical exams and lab studies.
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