Chapter 4: The Complete Health History

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Questions and Answers

What is the main purpose of collecting health history?

To combine with objective data to form a complete picture of patient's health status (correct)
To provide a printed or electronic format for review
To perform physical exams and lab studies
To form the database for laboratory studies

What is the sequence of obtaining information in a health history?

Biographic data, source of history, review of systems
Biographic data, family history, review of systems
Biographic data, source of history, reason for seeking care (correct)
Present health, past health, family history

What is included in the review of systems?

Source of history and reason for seeking care
Functional assessment including activities of daily living (ADLs) (correct)
Biographic data and present health
Past health and family history

Why may the focus of a health history differ?

Depending on the clinical practice setting and/or nature of complaint (B) Signup and view all the answers

What is an area of focus in a health history?

Developmental considerations (A) Signup and view all the answers

What is a health history used for?

As a screening tool for detection of abnormalities (D) Signup and view all the answers

What is the primary focus of obtaining a patient's past medical history?

To obtain specific pertinent information for better clinical decision making (A) Signup and view all the answers

Which of the following options is considered a well-described clinical symptom?

A clinical symptom with precipitating and alleviating factors (B) Signup and view all the answers

What is the impact of comorbidities on a patient's health status?

It has a pronounced effect on present and future health (C) Signup and view all the answers

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 (B) Signup and view all the answers

Why is it essential to obtain detailed information about a patient's past medical history?

To provide cues for better clinical decision making (D) Signup and view all the answers

What is included in the documentation of a patient's operations?

The facility, name of healthcare provider, and date of procedures (B) Signup and view all the answers

What is the primary purpose of obtaining a family history?

To determine the risk of genetic diseases (C) Signup and view all the answers

What is the purpose of including biographic data in cross-cultural care?

To determine the patient's spiritual resources and religion (A) Signup and view all the answers

What is the purpose of correlating allergies with CDC Guidelines?

To ensure proper immunization administration (D) Signup and view all the answers

What is the primary purpose of a pedigree or genogram in family history?

To standardize the collection of family history data (B) Signup and view all the answers

What is included in the assessment of prenatal, perinatal, and postnatal status?

childhood illnesses and potential complications (C) Signup and view all the answers

What is the purpose of including the postpartum course in obstetric history?

To provide relevant information about childbearing experiences (A) Signup and view all the answers

What is the purpose of performing medication reconciliation?

To ensure that all prescribed and over-the-counter medications are accounted for (A) Signup and view all the answers

What is the purpose of documenting the reason for care and hospital facility location?

to obtain information about operations or hospitalizations (D) Signup and view all the answers

What is included in the assessment of childhood illnesses?

age of occurrence, types of illness, and potential complications (C) Signup and view all the answers

What is the purpose of documenting immunizations per CDC recommendations?

to ensure adherence to established guidelines (A) Signup and view all the answers

What is included in the assessment of medications?

dosage, schedule, and clinical indication (C) Signup and view all the answers

What is the purpose of documenting growth and developmental milestones?

to assess and reassess growth and developmental achievements across life cycle (C) Signup and view all the answers

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 (C) Signup and view all the answers

What is the primary goal of a review of systems for a child?

To focus on specific body systems and health promotion (A) Signup and view all the answers

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 (D) Signup and view all the answers

What is the primary consideration when assessing the general health state of a child?

Cognitive and developmental age-appropriate behaviors (D) Signup and view all the answers

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 (D) Signup and view all the answers

What is the primary focus of a health history for a child?

Focusing on specific body systems and health promotion (A) Signup and view all the answers

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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.

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

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