Podcast
Questions and Answers
Which of the following is NOT a primary purpose of completing a complete health history?
Which of the following is NOT a primary purpose of completing a complete health history?
- To collect subjective and objective data
- To determine the patient's favorite color (correct)
- To assess lifestyle, exercise, and dietary habits
- To provide a complete picture of the patient’s past and present health
The patient's chart is considered a primary source of data.
The patient's chart is considered a primary source of data.
False (B)
What mnemonic is used to gather information about a present health problem?
What mnemonic is used to gather information about a present health problem?
OLDCARTS or PQRSTU
A functional assessment measures a person's ability to perform activities of daily living, also known as ________.
A functional assessment measures a person's ability to perform activities of daily living, also known as ________.
Match the following components with their descriptions:
Match the following components with their descriptions:
For an ill patient, the present health status should include:
For an ill patient, the present health status should include:
HEEADSSS is a method of interviewing for adults.
HEEADSSS is a method of interviewing for adults.
Name THREE areas that are assessed in a functional assessment besides ADLs.
Name THREE areas that are assessed in a functional assessment besides ADLs.
Flashcards
Complete Health History
Complete Health History
A comprehensive medical history, covering past and present health, including lifestyle factors, illnesses, medications, and allergies. Used to gain a complete understanding of the patient's health status and inform treatment decisions.
Primary Data
Primary Data
Information gathered directly from the patient, detailing their subjective experiences and symptoms.
Secondary Data
Secondary Data
Information obtained from sources other than the patient, such as medical records, family members, or other healthcare providers.
Present Health Status
Present Health Status
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Past Health History
Past Health History
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Review of Systems
Review of Systems
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Functional Assessment (ADLs)
Functional Assessment (ADLs)
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HEEADSSS
HEEADSSS
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Study Notes
Purpose of a Complete Health History
- A complete health history is crucial for gathering both subjective and objective data.
- It paints a comprehensive picture of a patient's past and present health.
- It acknowledges and supports healthy lifestyle choices.
- For healthy individuals, it assesses lifestyle, exercise, diet, substance use, risk reduction, and health promotion.
- For ill individuals, it details the chronological record of their health issues.
Sources of Data
- Primary: The patient is the primary source of subjective data.
- Secondary: Data can come from the patient's medical records, family members, and other healthcare professionals.
Gathering Present and Past Health Status
- Well Person: Present health status can be summarized briefly, such as "I feel healthy."
- Ill Person: Detailed chronology of the reason for seeking care (from symptom onset) using OLDCARTS or PQRSTU.
- Past Health: Includes childhood illnesses, accidents, chronic diseases, hospitalizations, surgeries, obstetric history, immunizations, and recent examinations.
- Present Health: Current medical conditions, medication reconciliation, and allergies.
Review of Systems and Functional Assessments
- Review of systems evaluates each body system's past and present health to ensure no significant data is missed from the present illness section. It also assesses adherence to health promotion practices.
- Functional assessment measures a patient's ability to perform daily activities (ADLs): bathing, dressing, toileting, eating, and walking. It also measures instrumental ADLs (IADLs) for independent living: housekeeping, shopping, cooking, laundry, phone use, finances, nutrition, social relationships, self-concept/coping, and home environment.
Considerations for Different Ages
- Adolescents: Use HEEADSSS to assess home environment, education, eating habits, activities, drug use, sexuality, suicide/depression risk, and safety.
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Description
This quiz evaluates your understanding of the purpose and sources of a complete health history. It covers both subjective and objective data collection for healthy and ill individuals. Test your knowledge on how to assess health status and the importance of lifestyle choices.
