Podcast
Questions and Answers
During a health history interview, which stage involves building rapport with the client by explaining the purpose of the interview?
During a health history interview, which stage involves building rapport with the client by explaining the purpose of the interview?
- Closing stage
- Information gathering stage
- Opening stage (correct)
- Documentation stage
Using the acronym 'PLEASE' in the context of a health history interview, what does 'L' stand for?
Using the acronym 'PLEASE' in the context of a health history interview, what does 'L' stand for?
- Level of consciousness
- Lung capacity
- Last oral intake of liquids and food (correct)
- List of current providers
Why is it important to review a client's medical record prior to conducting a health history interview?
Why is it important to review a client's medical record prior to conducting a health history interview?
- To expedite the interview process.
- To have a broader understanding of the client’s previous clinical issues. (correct)
- To avoid asking redundant questions.
- To impress the client with your preparation.
Which of the following is the LEAST suitable location for conducting a health history interview?
Which of the following is the LEAST suitable location for conducting a health history interview?
During which stage of the health history interview would you summarize the information collected and thank the client for their participation?
During which stage of the health history interview would you summarize the information collected and thank the client for their participation?
A client mentions they are allergic to penicillin. According to the 'PLEASE' mnemonic, under which category would this information be documented?
A client mentions they are allergic to penicillin. According to the 'PLEASE' mnemonic, under which category would this information be documented?
Before beginning a health history interview, what is the MOST important planning step related to documentation?
Before beginning a health history interview, what is the MOST important planning step related to documentation?
Which aspect of the interview environment is MOST important for encouraging open communication during a health history interview?
Which aspect of the interview environment is MOST important for encouraging open communication during a health history interview?
A client reports noticing a new mole that has changed in size and color. Which of the initial questions would be MOST relevant to ask based on the provided content?
A client reports noticing a new mole that has changed in size and color. Which of the initial questions would be MOST relevant to ask based on the provided content?
During a health history interview, a client mentions experiencing occasional dizziness. Which follow-up question would be MOST effective in gathering more detailed information about this symptom?
During a health history interview, a client mentions experiencing occasional dizziness. Which follow-up question would be MOST effective in gathering more detailed information about this symptom?
A client who wears contact lenses is being asked about their eye health. What is a pertinent question to ask regarding their contact lens use?
A client who wears contact lenses is being asked about their eye health. What is a pertinent question to ask regarding their contact lens use?
A client reports experiencing a ringing sound in their ears. Which of the following is the MOST relevant follow-up question to understand this symptom further?
A client reports experiencing a ringing sound in their ears. Which of the following is the MOST relevant follow-up question to understand this symptom further?
When assessing a client's nose and sinuses, which question directly addresses a common respiratory-related allergy symptom?
When assessing a client's nose and sinuses, which question directly addresses a common respiratory-related allergy symptom?
A client mentions having sores in their mouth. Which additional question is MOST important to determine the nature of these sores?
A client mentions having sores in their mouth. Which additional question is MOST important to determine the nature of these sores?
A client reports experiencing neck pain and limited movement. Which question is MOST relevant to assess the musculoskeletal aspect of this issue?
A client reports experiencing neck pain and limited movement. Which question is MOST relevant to assess the musculoskeletal aspect of this issue?
When questioning a female client about breast health, which of the following is a critical question to include?
When questioning a female client about breast health, which of the following is a critical question to include?
A client describes their cough as productive. What is the MOST important follow-up question to further characterize this symptom?
A client describes their cough as productive. What is the MOST important follow-up question to further characterize this symptom?
A client with a history of hypertension is being assessed. Which question is MOST directly related to monitoring a potential cardiovascular symptom?
A client with a history of hypertension is being assessed. Which question is MOST directly related to monitoring a potential cardiovascular symptom?
A client reports experiencing palpitations. What is the BEST way to clarify this symptom during a health history interview?
A client reports experiencing palpitations. What is the BEST way to clarify this symptom during a health history interview?
A client reports waking up at night feeling short of breath. Which question is MOST relevant to further evaluate this symptom in relation to cardiac function?
A client reports waking up at night feeling short of breath. Which question is MOST relevant to further evaluate this symptom in relation to cardiac function?
When assessing a client for peripheral vascular issues, which question is MOST pertinent to assess for arterial insufficiency in the lower extremities?
When assessing a client for peripheral vascular issues, which question is MOST pertinent to assess for arterial insufficiency in the lower extremities?
A client is being asked about their bowel habits. What is an essential question to determine a potential gastrointestinal red flag?
A client is being asked about their bowel habits. What is an essential question to determine a potential gastrointestinal red flag?
To understand a client's typical bowel function, which of the following questions is MOST appropriate during a gastrointestinal assessment?
To understand a client's typical bowel function, which of the following questions is MOST appropriate during a gastrointestinal assessment?
Why is it important for a nurse to ensure privacy when asking a client about potential maltreatment?
Why is it important for a nurse to ensure privacy when asking a client about potential maltreatment?
A client is hesitant to answer questions about their relationship with their caretaker. What should the nurse do to ensure the client's safety and well-being?
A client is hesitant to answer questions about their relationship with their caretaker. What should the nurse do to ensure the client's safety and well-being?
Which of the following reflects how a nurse should ideally structure a health history interview?
Which of the following reflects how a nurse should ideally structure a health history interview?
A nurse is gathering information about a client's various body systems. Which approach ensures a comprehensive and systematic assessment?
A nurse is gathering information about a client's various body systems. Which approach ensures a comprehensive and systematic assessment?
After completing a health history interview, what is the most important step a nurse should take regarding the collected information?
After completing a health history interview, what is the most important step a nurse should take regarding the collected information?
Which of the following is the MOST direct application of understanding a client's social determinants of health during health history taking?
Which of the following is the MOST direct application of understanding a client's social determinants of health during health history taking?
When a client reports a history of asthma, at what point during the health assessment should a nurse gather detailed information about this condition?
When a client reports a history of asthma, at what point during the health assessment should a nurse gather detailed information about this condition?
In the 'funnel approach' to health history interviewing, what is the purpose of starting with general questions before moving to specific inquiries?
In the 'funnel approach' to health history interviewing, what is the purpose of starting with general questions before moving to specific inquiries?
Which of the following childhood illnesses is it MOST important to inquire about specifically due to potential long-term complications?
Which of the following childhood illnesses is it MOST important to inquire about specifically due to potential long-term complications?
When documenting a client's injury history, which detail is MOST crucial to record for each significant injury?
When documenting a client's injury history, which detail is MOST crucial to record for each significant injury?
Inquiring about chronic illnesses during a health history is essential because it helps to:
Inquiring about chronic illnesses during a health history is essential because it helps to:
What is the primary reason for documenting the dates and reasons for a client's hospitalizations during health history taking?
What is the primary reason for documenting the dates and reasons for a client's hospitalizations during health history taking?
Why is it important to ask about the type of surgery a client has undergone, in addition to whether they have had surgery at all?
Why is it important to ask about the type of surgery a client has undergone, in addition to whether they have had surgery at all?
For an adult client, which of the following immunizations is generally recommended annually?
For an adult client, which of the following immunizations is generally recommended annually?
Asking a client about health maintenance examinations and screenings is important for understanding their:
Asking a client about health maintenance examinations and screenings is important for understanding their:
When asking about allergies, it is MOST important to differentiate between a true allergic reaction and:
When asking about allergies, it is MOST important to differentiate between a true allergic reaction and:
What is the primary goal of medication reconciliation during health history taking?
What is the primary goal of medication reconciliation during health history taking?
For a client over 60 years old, which vaccine is specifically recommended to prevent a painful condition caused by the reactivation of the chickenpox virus?
For a client over 60 years old, which vaccine is specifically recommended to prevent a painful condition caused by the reactivation of the chickenpox virus?
Which of the following is an example of a social and community context determinant of health?
Which of the following is an example of a social and community context determinant of health?
If a client reports experiencing nausea after taking a medication, how should a nurse initially classify this reaction when documenting allergies?
If a client reports experiencing nausea after taking a medication, how should a nurse initially classify this reaction when documenting allergies?
A client reports experiencing significant stress due to work and family responsibilities. Which question is MOST effective in understanding their stress management strategies?
A client reports experiencing significant stress due to work and family responsibilities. Which question is MOST effective in understanding their stress management strategies?
When assessing a client's Activities of Daily Living (ADLs), which of the following questions would be MOST relevant to functional mobility?
When assessing a client's Activities of Daily Living (ADLs), which of the following questions would be MOST relevant to functional mobility?
A client mentions difficulty falling asleep and staying asleep. To understand their sleep pattern comprehensively, which of the following is the MOST important initial question?
A client mentions difficulty falling asleep and staying asleep. To understand their sleep pattern comprehensively, which of the following is the MOST important initial question?
Using the FICA framework to assess spirituality, asking 'How does your religious faith or spirituality guide your health choices and practices?' addresses which component?
Using the FICA framework to assess spirituality, asking 'How does your religious faith or spirituality guide your health choices and practices?' addresses which component?
When assessing alcohol use, which of the following questions is MOST direct and appropriate for determining recent consumption patterns?
When assessing alcohol use, which of the following questions is MOST direct and appropriate for determining recent consumption patterns?
A client reports smoking half a pack of cigarettes daily for 10 years but quit 2 years ago. What is the MOST important information to document regarding their tobacco use history?
A client reports smoking half a pack of cigarettes daily for 10 years but quit 2 years ago. What is the MOST important information to document regarding their tobacco use history?
When inquiring about recreational drug use, which approach is MOST likely to elicit honest and comprehensive information from a client?
When inquiring about recreational drug use, which approach is MOST likely to elicit honest and comprehensive information from a client?
In occupational health assessment, asking 'Does your occupation expose you to health hazards such as noxious fumes, fertilizer, or other chemicals?' primarily addresses which aspect?
In occupational health assessment, asking 'Does your occupation expose you to health hazards such as noxious fumes, fertilizer, or other chemicals?' primarily addresses which aspect?
Assessing the living environment includes inquiring about smoke and carbon monoxide detectors. What is the PRIMARY health and safety reason for this question?
Assessing the living environment includes inquiring about smoke and carbon monoxide detectors. What is the PRIMARY health and safety reason for this question?
When assessing a client's relationships, asking 'Is there a family member or friend that you could reach out to if you needed help or support?' is MOST important for understanding their:
When assessing a client's relationships, asking 'Is there a family member or friend that you could reach out to if you needed help or support?' is MOST important for understanding their:
Screening for maltreatment is a critical aspect of client assessment. Which of the following BEST describes the scope of maltreatment screening in this context?
Screening for maltreatment is a critical aspect of client assessment. Which of the following BEST describes the scope of maltreatment screening in this context?
A client states they 'sometimes' use a cane for walking due to knee pain. To further assess their mobility, what is the MOST appropriate NEXT question?
A client states they 'sometimes' use a cane for walking due to knee pain. To further assess their mobility, what is the MOST appropriate NEXT question?
A client reports feeling 'not very rested' after sleeping 8 hours per night. Which follow-up question is MOST helpful in understanding the potential issue?
A client reports feeling 'not very rested' after sleeping 8 hours per night. Which follow-up question is MOST helpful in understanding the potential issue?
When using the FICA framework, asking 'Do you participate in a religious or spiritual community?' addresses which component of spiritual assessment?
When using the FICA framework, asking 'Do you participate in a religious or spiritual community?' addresses which component of spiritual assessment?
A client discloses using prescription pain medication 'more often than prescribed' due to chronic back pain. Which of the following is the MOST important follow-up question to assess potential substance use issues?
A client discloses using prescription pain medication 'more often than prescribed' due to chronic back pain. Which of the following is the MOST important follow-up question to assess potential substance use issues?
A client reports taking an herbal supplement for improved sleep. Which of the following details is MOST important to gather about this supplement?
A client reports taking an herbal supplement for improved sleep. Which of the following details is MOST important to gather about this supplement?
When asking a client about their nutritional habits, which question would be MOST effective in understanding their typical daily food intake?
When asking a client about their nutritional habits, which question would be MOST effective in understanding their typical daily food intake?
A client is a 35-year-old female. She reports two pregnancies, one resulting in a term birth and one miscarriage. How would you document this obstetrical history using GTPAL?
A client is a 35-year-old female. She reports two pregnancies, one resulting in a term birth and one miscarriage. How would you document this obstetrical history using GTPAL?
When assessing a client's emotional and psychological history, inquiring about their coping strategies is important to understand:
When assessing a client's emotional and psychological history, inquiring about their coping strategies is important to understand:
Why is it important to ask about genetically linked diseases in a family health history?
Why is it important to ask about genetically linked diseases in a family health history?
After collecting a client's health history, summarizing the findings for the client is MOST important because it:
After collecting a client's health history, summarizing the findings for the client is MOST important because it:
The primary purpose of conducting a review of body systems is to:
The primary purpose of conducting a review of body systems is to:
A client reports experiencing pain during the health history interview. What is the MOST appropriate initial action?
A client reports experiencing pain during the health history interview. What is the MOST appropriate initial action?
For a transgender client assigned female at birth, why is it important to ask about gender-affirming treatments when obtaining an obstetrical history?
For a transgender client assigned female at birth, why is it important to ask about gender-affirming treatments when obtaining an obstetrical history?
Asking a client about their support system is MOST relevant to understanding their:
Asking a client about their support system is MOST relevant to understanding their:
When taking a family health history, focusing on three generations of blood relatives is important primarily because:
When taking a family health history, focusing on three generations of blood relatives is important primarily because:
When inquiring about Over-The-Counter (OTC) medications, which of the following is the MOST crucial detail to ascertain?
When inquiring about Over-The-Counter (OTC) medications, which of the following is the MOST crucial detail to ascertain?
A recent change in a client's appetite is MOST relevant to which aspect of their health assessment?
A recent change in a client's appetite is MOST relevant to which aspect of their health assessment?
In the GTPAL obstetric history format, 'A' specifically represents:
In the GTPAL obstetric history format, 'A' specifically represents:
Initiating the overall health assessment with easy-to-answer questions, such as about recent weight changes or fatigue, primarily serves to:
Initiating the overall health assessment with easy-to-answer questions, such as about recent weight changes or fatigue, primarily serves to:
What is the primary reason for a nurse to position themselves face-to-face and within 2 to 3 feet of a client during an interview?
What is the primary reason for a nurse to position themselves face-to-face and within 2 to 3 feet of a client during an interview?
Why should a nurse avoid being at a significantly higher position than their client during an interview?
Why should a nurse avoid being at a significantly higher position than their client during an interview?
Which action should the nurse prioritize when a client reports experiencing pain before an interview?
Which action should the nurse prioritize when a client reports experiencing pain before an interview?
Why is it important to record the specific date and time of a client interview in health history documentation?
Why is it important to record the specific date and time of a client interview in health history documentation?
What is the primary reason for documenting a client's preferred language in their health record?
What is the primary reason for documenting a client's preferred language in their health record?
Why is it generally not recommended to use family members or friends as interpreters for healthcare communication?
Why is it generally not recommended to use family members or friends as interpreters for healthcare communication?
When using a professional interpreter during a client interview, which of the following strategies should the nurse employ?
When using a professional interpreter during a client interview, which of the following strategies should the nurse employ?
When documenting the source of information obtained during a health history interview, what level of detail is necessary?
When documenting the source of information obtained during a health history interview, what level of detail is necessary?
What is the primary reason for beginning a client interview by collecting biographic data?
What is the primary reason for beginning a client interview by collecting biographic data?
Why is it important to ask a client about any illnesses or medical disabilities that could affect their daily living or social interactions?
Why is it important to ask a client about any illnesses or medical disabilities that could affect their daily living or social interactions?
How should a nurse approach the topic of gender identity with a client during a health history interview?
How should a nurse approach the topic of gender identity with a client during a health history interview?
When documenting a client's reason for seeking care, why is it important to use the client's own words?
When documenting a client's reason for seeking care, why is it important to use the client's own words?
After obtaining a client's reason for seeking care, what is the next appropriate step in gathering the history of present illness?
After obtaining a client's reason for seeking care, what is the next appropriate step in gathering the history of present illness?
When exploring the history of a present illness, which aspect of a symptom is addressed by asking about 'aggravating and alleviating factors'?
When exploring the history of a present illness, which aspect of a symptom is addressed by asking about 'aggravating and alleviating factors'?
What is the primary purpose of using the mnemonic 'OLD CARTS' when gathering details about a client's presenting problem?
What is the primary purpose of using the mnemonic 'OLD CARTS' when gathering details about a client's presenting problem?
Which of the following questions is LEAST relevant when assessing a male client's reproductive health?
Which of the following questions is LEAST relevant when assessing a male client's reproductive health?
A client reports experiencing hesitancy and straining during urination. Which system should the nurse prioritize for further evaluation?
A client reports experiencing hesitancy and straining during urination. Which system should the nurse prioritize for further evaluation?
Which of the following findings should prompt the nurse to ask further questions regarding potential hematologic issues?
Which of the following findings should prompt the nurse to ask further questions regarding potential hematologic issues?
A client with a history of scoliosis reports experiencing increasing pain and difficulty with movement. Which system is MOST relevant to assess further?
A client with a history of scoliosis reports experiencing increasing pain and difficulty with movement. Which system is MOST relevant to assess further?
A client reports experiencing 'rapid up-and-down mood swings'. Which term BEST describes this phenomenon, and which system is MOST relevant?
A client reports experiencing 'rapid up-and-down mood swings'. Which term BEST describes this phenomenon, and which system is MOST relevant?
A client reports a recent onset of excessive thirst, frequent urination, and increased hunger. Which system would the nurse primarily assess based on these symptoms?
A client reports a recent onset of excessive thirst, frequent urination, and increased hunger. Which system would the nurse primarily assess based on these symptoms?
When conducting a functional assessment, which element is MOST important to ensure due to the sensitive nature of the topics?
When conducting a functional assessment, which element is MOST important to ensure due to the sensitive nature of the topics?
Which component of self-concept involves a client's perception of their physical attractiveness and health?
Which component of self-concept involves a client's perception of their physical attractiveness and health?
Which question would be MOST appropriate for assessing a client's role performance during a functional assessment?
Which question would be MOST appropriate for assessing a client's role performance during a functional assessment?
Assessing health literacy is essential to ensure that clients can:
Assessing health literacy is essential to ensure that clients can:
Which question BEST assesses a client's personal identity during a functional assessment?
Which question BEST assesses a client's personal identity during a functional assessment?
A client reports difficulty with balance and coordination. Which specific term describes this symptom, and to which system does it primarily relate?
A client reports difficulty with balance and coordination. Which specific term describes this symptom, and to which system does it primarily relate?
For a female client, which question is MOST important to include when assessing their reproductive health?
For a female client, which question is MOST important to include when assessing their reproductive health?
A client describes experiencing an 'aura' before a seizure. What does the presence of an aura suggest?
A client describes experiencing an 'aura' before a seizure. What does the presence of an aura suggest?
Which of the following questions would be MOST appropriate when assessing a client's body image during a functional assessment?
Which of the following questions would be MOST appropriate when assessing a client's body image during a functional assessment?
Flashcards
Health History Interview
Health History Interview
A structured conversation to gather details about the client's background and current medical status.
PLEASE Acronym
PLEASE Acronym
P - Past medical history, L - Last oral intake, E - Events leading to illness, A - Allergies, S - Symptoms, E - Each medication.
Interview Stages
Interview Stages
Opening stage (introduction), information gathering stage (body), and closing stage (summary).
Medical Record Review
Medical Record Review
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Interview Planning
Interview Planning
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Optimal Interview Environment
Optimal Interview Environment
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Past Medical History
Past Medical History
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Allergies
Allergies
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Ideal Interview Distance
Ideal Interview Distance
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Interview Demeanor
Interview Demeanor
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Pain and Interview Focus
Pain and Interview Focus
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Assessing Pain
Assessing Pain
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Initial Documentation
Initial Documentation
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Preferred Language
Preferred Language
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Language Line
Language Line
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Using an Interpreter
Using an Interpreter
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Source of Information
Source of Information
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Biographic Data Use
Biographic Data Use
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Confirming Client Details
Confirming Client Details
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Assigned Sex
Assigned Sex
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Gender Identity
Gender Identity
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Reason for Seeking Care
Reason for Seeking Care
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OLD CARTS
OLD CARTS
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IPV/Abuse Screening
IPV/Abuse Screening
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Human Trafficking Screening
Human Trafficking Screening
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Elder/Disabled Maltreatment Screening
Elder/Disabled Maltreatment Screening
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Systematic Data Collection
Systematic Data Collection
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Documentation Importance
Documentation Importance
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Medication List
Medication List
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Nutrition Assessment
Nutrition Assessment
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GTPAL
GTPAL
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Gravida (G)
Gravida (G)
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Term (T)
Term (T)
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Preterm (P)
Preterm (P)
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Abortion (A)
Abortion (A)
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Living (L)
Living (L)
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Emotional/Psychological History
Emotional/Psychological History
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Family Health History
Family Health History
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Genetically Linked Diseases
Genetically Linked Diseases
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Neurological/Psychological Disorders
Neurological/Psychological Disorders
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Cardiac Diseases (Family History)
Cardiac Diseases (Family History)
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Endocrine Problems (Family History)
Endocrine Problems (Family History)
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Summary of Findings
Summary of Findings
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Social Determinants of Health
Social Determinants of Health
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Health History Funnel
Health History Funnel
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Childhood Illnesses (Health History)
Childhood Illnesses (Health History)
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Injuries (Health History)
Injuries (Health History)
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Chronic Illnesses (Health History)
Chronic Illnesses (Health History)
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Hospitalizations (Health History)
Hospitalizations (Health History)
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Surgeries (Health History)
Surgeries (Health History)
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Immunizations (Health History)
Immunizations (Health History)
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Health Maintenance Exams
Health Maintenance Exams
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Health Screenings
Health Screenings
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Allergies (Health History)
Allergies (Health History)
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Current Medications
Current Medications
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Annual Influenza Vaccine
Annual Influenza Vaccine
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Tetanus-diphtheria-pertussis (Tdap)
Tetanus-diphtheria-pertussis (Tdap)
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Shingles Vaccine
Shingles Vaccine
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Genitourinary System Evaluation
Genitourinary System Evaluation
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Urinary Health Assessment
Urinary Health Assessment
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Reproductive Health Questions
Reproductive Health Questions
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Whole-Body Systems Assessment
Whole-Body Systems Assessment
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Musculoskeletal System Check
Musculoskeletal System Check
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Neurologic System Assessment
Neurologic System Assessment
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Hematologic System Questions
Hematologic System Questions
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Endocrine System Evaluation
Endocrine System Evaluation
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Functional Assessment
Functional Assessment
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Functional Assessment Investigates
Functional Assessment Investigates
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Functional Assessment Diversity
Functional Assessment Diversity
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Self-Concept Components
Self-Concept Components
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Body Image Definition
Body Image Definition
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Health Literacy
Health Literacy
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Assessing Health Literacy
Assessing Health Literacy
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Skin, Nail, and Hair History
Skin, Nail, and Hair History
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Characteristics of Headache
Characteristics of Headache
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Dizziness/Lightheadedness
Dizziness/Lightheadedness
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Head Trauma History
Head Trauma History
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Eye Examination History
Eye Examination History
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Ear and Hearing Assessment
Ear and Hearing Assessment
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Nose and Sinus Issues
Nose and Sinus Issues
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Mouth and Throat Assessment
Mouth and Throat Assessment
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Neck Assessment
Neck Assessment
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Breast Assessment
Breast Assessment
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Respiratory History
Respiratory History
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Cardiac Assessment
Cardiac Assessment
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Peripheral Vascular System Assessment
Peripheral Vascular System Assessment
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Gastrointestinal History
Gastrointestinal History
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Stool Characteristics
Stool Characteristics
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Stress Assessment
Stress Assessment
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Activities of Daily Living (ADLs)
Activities of Daily Living (ADLs)
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Sleep Pattern Assessment
Sleep Pattern Assessment
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FICA (Spirituality)
FICA (Spirituality)
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Alcohol Use Assessment
Alcohol Use Assessment
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Tobacco/Nicotine Use Assessment
Tobacco/Nicotine Use Assessment
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Recreational Drug Use Assessment
Recreational Drug Use Assessment
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Occupational Health Assessment
Occupational Health Assessment
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Living Environment Assessment
Living Environment Assessment
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Relationship Assessment
Relationship Assessment
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Maltreatment Screening
Maltreatment Screening
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Sleep Pattern
Sleep Pattern
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Daily Tasks
Daily Tasks
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Tobacco History
Tobacco History
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Stress Causes
Stress Causes
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Study Notes
- The goal of a health history interview is to gather relevant details about a client's background and current medical status to provide personalized healthcare.
PLEASE Acronym for Health Interview
- P - Past medical history: previous illnesses, and state of health
- L - Last oral intake: liquids and food
- E - Events leading to illness or injury
- A - Allergies: and type of reactions
- S - Symptoms: or chief complaint
- E - Each: prescribed medication, OTC medications, and herbal supplements
Stages of a Health History Interview
- Opening stage: introduce yourself and explain the purpose of the interview to establish rapport.
- Information gathering stage: use therapeutic communication to collect and document client data.
- Closing stage: thank the client, answer questions, and summarize information.
Planning for the Interview
- Familiarize yourself with the documentation method.
- Gather necessary note-taking tools.
- Determine the available time with the client.
Medical Record Review
- Access and review the client’s medical record for a broader understanding of previous clinical issues.
- Use the record to formulate relevant questions and validate understanding during the interview.
Time and Place Considerations
- Schedule at a convenient time and place for both interviewer and client.
- Conduct interviews in private settings with proper lighting and ventilation.
- Avoid waiting rooms or reception areas.
Seating Arrangement
- Sit 2-3 feet away from the client, face-to-face.
- Maintain eye contact and avoid speaking loudly.
- Ensure you are not at a significantly higher position than the client to avoid asserting power.
Addressing Pain
- Ask about pain levels before starting the interview.
- Intervene to reduce discomfort if the client is in pain.
- Document pain-relieving interventions and their effects.
Current Health Documentation
- Record the date, time, and preferred language of the interview.
- Arrange for an interpreter if needed.
- Using the client’s preferred language increases communication accuracy and satisfaction.
- Avoid using family or friends as interpreters due to privacy concerns.
- When using an interpreter, speak in the first person, directly to the client, in short sentences, and avoid medical terminology.
- Document the source of information: client, family member, interpreter, or medical record.
Biographic Data Collection
- Collect client's name, address, phone number, age, and date of birth; verify against medical records.
- Ask about any illness or medical disability affecting daily living or social interactions.
- Inquire about an emergency contact person.
Gender Identity Questions
- Determine gender identity to ask relevant questions and use appropriate language.
- Assigned sex: biologic sex assigned at birth.
- Gender identity: an individual’s internal sense of gender.
- Transgender: identifying as a gender incongruent with assigned sex at birth.
- Respect client's right to privacy regarding sex, gender, and sexual orientation.
- Ask about sex assigned at birth, gender identity, and preferred pronouns.
Reason for Seeking Care
- Record a statement of overall health for healthy clients.
- For ill or injured clients, document the "chief complaint" or "presenting problem" in their own words.
- Note signs of illness/injury and duration of the issue.
- Interpret and validate responses by summarizing back to the client.
History of Present Illness
- Document the appearance of manifestations in chronological order.
- Note the location, characteristics, severity, timing, and setting of each symptom.
- Inquire about aggravating, relieving, and associated factors.
- Record the client’s perception of the meaning of the illness or injury.
- Interpret and validate understanding by summarizing the collected data.
OLD CARTS Acronym for Presenting Problem
- O - Onset: When symptoms began
- L - Location: Where symptoms occur
- D - Duration: How long symptoms last
- C - Characteristics: The characteristics of the symptoms
- A - Aggravating and alleviating factors: What affects the symptoms
- R - Related symptoms: Other symptoms that are present
- T - Treatment: What treatments have been tried
- S - Severity: How severe symptoms are
Social Determinants of Health
- Consider social and economic opportunities affecting health.
- Address economic stability, education access, social context, healthcare access, and the built environment.
- Connect the client with available community resources and support if needed.
Medical History: General Data Collection
- Gather details of the client’s medical history and that of their family members.
- Start with general questions and funnel down to specific inquiries.
- Indicate negative responses for completeness.
- Interpret and validate responses by summarizing them.
Childhood Illnesses
- Ask about illnesses experienced as a child.
- Note complications from infections like measles, mumps, rubella, chickenpox, whooping cough, polio, rheumatic fever, or scarlet fever.
Injuries
- Determine any significant injuries, such as auto accidents, fractures, head injuries, wounds, or burns.
- Note dates and outcomes.
Chronic Illnesses
- Inquire about serious or chronic illnesses such as asthma, diabetes, seizures, sickle cell anemia, hepatitis, or heart disease.
Hospitalizations
- Question about hospitalizations due to illness.
- Note the reason, date, and length of hospitalization.
Surgeries
- Determine if the client has had any surgical procedures.
- Detail the type of surgery, when it occurred, and outcome.
Immunizations
- Ask about recommended immunizations based on age, lifestyle, and health status.
- Adults should have annual influenza, tetanus-diphtheria-pertussis (Tdap), measles-mumps-rubella (MMR), human papilloma virus (HPV), varicella, and COVID-19 vaccinations.
- Additional may include hepatitis A and B, pneumococcal, meningococcal, and haemophilus influenzae type B.
- International clients may have received Bacillus Calmette-Guérin (BCG) for tuberculosis.
Health Maintenance Examinations and Screenings
- Question when the client last had a medical, dental, and vision assessment.
- Determine if the client has participated in routine health screenings.
- Examples include colonoscopy, cholesterol levels, tuberculin skin test, mammogram, and Pap smears.
Allergies
- Inquire about allergic reactions to food, medications, or environmental triggers, such as latex.
- Document the type of reaction to each allergen.
- Document true allergic reactions, not unpleasant side effects.
Current Medications (Medication Reconciliation)
- Ensure an accurate record of the client’s current medications, including supplements, herbal compounds, and OTC medications.
- Document the name, dosage, frequency, and reason for each medication.
Nutrition
- Ask about current eating habits and appetite.
- Determine if the client has noted recent weight changes.
Obstetrical History
- For clients of childbearing age, ask about obstetrical history using the GTPAL format.
- G - Gravida: total number of pregnancies
- T - Term: number of pregnancies carried to within 2 weeks of due date
- P - Preterm: number of pregnancies delivered more than 2 weeks before due date
- A - Abortion: spontaneous or induced
- L - Living: current number of living children.
GTPAL for Transgender Clients
- For transgender clients of child-bearing age, obtain an obstetrical history.
- Include GTPAL and any gender-affirming treatments or surgeries.
- Note the date of any gender-affirming surgery.
Emotional and Psychological History
- Ask the client to describe their emotional and psychological history.
- Assess current stress levels, coping strategies, and previous counseling or mental health care.
- Inquire about recent losses and the client’s support system.
Family Health History
- Concentrate on the health of three generations of blood relatives.
- Ask about the health of grandparents, parents, and siblings.
- Note the age and cause of death for any deceased family members.
- Genetic Component Enquiries
- Blood disorders, obesity, kidney disease, or cancer of the breast, colon, prostate, or ovaries
- Neurological or psychological disorders such as mental illness, stroke, seizures, substance use disorders, or dementia and Alzheimer’s disease
- Cardiac diseases such as heart attacks, high blood pressure, or elevated cholesterol levels
- Endocrine problems such as diabetes or thyroid diseases
- Arthritis
- Asthma or tuberculosis
- Allergic reactions to medications, foods, or environmental triggers
Summary of Health History
- Summarize findings for the client to ensure interpretation accuracy.
Review of Systems Interview
- Document the client’s health history, then evaluate systems in a head-to-toe manner.
- Purpose: evaluate overall health and identify unexpected manifestations.
- If painful symptoms are reported, address the symptom first.
- Interpret and validate the responses by repeating a summary back to the client.
Overall Health Questions
- Include questions such as:
- Recent weight loss or gain?
- Experiencing fatigue or tiredness?
- Current level of stress?
- Experiencing any discomfort?
Skin Evaluation
- History of skin disease?
- Changes in skin or nails?
- Changes in hair growth pattern or texture?
Head and Neck Questions
- Headaches: location and sensation?
- Dizziness or lightheadedness? Ask for description inside quotations.
- Head trauma or injury (loss of consciousness)?
Eye Examination
- Glasses or contact lenses?
- Last eye examination date?
- Chronic eye conditions?
- Recent visual changes: blurred vision, double vision, or eye pain?
- Discharge or excessive tearing?
Ears Interview
- Wearing a hearing aid?
- Recent hearing changes, such as less ability to hear or a ringing sound?
- Frequent earaches?
- Fluid draining from ears?
Nose and Sinuses Interview
- Nasal discharge?
- Nosebleeds?
- Allergies to environmental substances?
- Change in sense of smell?
- Snoring?
Mouth and Throat Interview
- Dentures or bridges?
- Pain or sensitivity to heat or cold in teeth or gums?
- Bleeding or swelling of gums?
- Sores or lesions in mouth or on tongue?
- Hoarse or strained voice?
- Sore throat?
- Difficulty swallowing?
- Change in sense of taste?
Neck and Throat Interview
- Tenderness in neck muscles?
- Enlarged lymph nodes, lumps, or swelling in neck?
- Pain or limitations to neck movement?
Breast and Lymphatics Interview
- History of breast conditions?
- Breast surgery?
- Lumps, pain, or difference in breast tissue?
- Drainage from nipples?
- Tenderness, pain, lumps, or swelling in the axilla (underarms)?
Respiratory System Examination
- History of lung disease or chronic lung condition?
- Difficulty breathing or shortness of breath?
- Precipitating factors?
- Recent cough (dry or productive)?
- Characteristics of material produced by the lungs?
- Last screening test for tuberculosis (TB)?
Cardiac and Peripheral Vascular System Interview
- History of heart condition?
- Reports of chest pain, tightness, or discomfort?
- Irregular heart rhythms or palpitations?
- Shortness of breath during the day or while sleeping?
- Waking up at night feeling short of breath?
- Heart or blood vessel surgery?
- Swelling of hands or lower extremities?
- Sensations of coldness, numbness, or tingling in hands and feet?
- Change in color of extremities?
- Calf or leg pain relieved with rest?
Gastrointestinal System Review
- History of abdominal diseases?
- History of liver, gallbladder, appendix, or intestines?
- Colitis, ulcer, or irritable bowel disease?
- Changes in appetite or food Intolerances?
- Nausea, vomiting, heartburn, constipation, or diarrhea?
- Pain with food, when stomach is empty, or after eating?
- Stool patterns?
- Pain or difficulty with defecation?
- Stool color?
- Blood in stools?
- Hemorrhoids?
- Laxative or antacid use?
- Screening for colon cancer?
Genitourinary System Review
- Urinary
- History of urinary problems, such as kidney stones or kidney failure?
- Pain upon urination, hesitancy, or straining?
- Changes in urinary frequency?
- Flank or suprapubic pain, dribbling, or incontinence?
- Urine color?
- Reproductive:
- Ask about gender identity and sexual orientation.
- Questions about sexual health: contraceptives and history of sexually transmitted infections.
- Pain or difficulty with sex?
- Description of sexual activity, number of partners, and type of activity.
- Male:
- Pain or sores on genitalia
- Lumps in the groin or testicles?
- Monthly testicular examination?
- Female
- Lesions, discharge, or pelvic pain
- Onset/ending of menstruation
- Menstrual pain or premenstrual symptoms (PMS)?
- Description of menstrual cycle.
- Postmenopausal bleeding if menses has ended?
- First day of last menstrual period and duration?
Musculoskeletal System Interview
- History of musculoskeletal disorders such as scoliosis, arthritis, or gout?
- Pain, stiffness, or difficulty with movement?
- Swelling, redness, warmth, or deformity of the joints?
- Difficulty performing activities of daily living (ADLs)?
Neurologic System Interview
- Difficulty with coordination, ataxia (balance), paralysis, numbness, weakness, tremors, or spasms?
- Interference with ADLs?
- History of fainting?
- Memory loss, forgetfulness, personality changes, or emotional lability (rapid mood swings)?
- Spasms, pain, numbness, tingling, or paralysis of extremities?
- History of seizures: description and presence of an aura?
Hematologic System Interview
- Bleeding issues or tendencies?
- Unusual bruising?
- History of transfusions or transfusion reaction?
Endocrine System Interview
- Excessive thirst, hunger, or urination?
- Heat and cold intolerances?
- Diagnosis of diabetes or thyroid disorder?
Functional Assessment Overview
- Determines client's ability to care for themselves when not experiencing acute illness.
- Investigates lifestyle, living environment, and ability to perform daily activities.
- Alterations can be caused by internal and external factors.
Internal Factors Review
- Sensitive topics require privacy.
- Variations occur based on age, ethnicity, culture, sexual orientation, and comorbidities.
- Ensure client is not requiring pain relief before starting.
Self-Concept Assessment
- Includes self-esteem, body image, role performance, and personal identity.
- Self-esteem - views themself and their self-worth.
- Body image - attitude toward physical appearance, health, strength, and sexuality.
- Role performance - ability to meet responsibilities at work, home, and in relationships.
- Personal identity - ability to be authentic with self and others, including sexuality and gender identity.
Health Literacy Assessment
- Assesses the ability to navigate, understand, and use health information.
- Determines the ability to read prescriptions and understand health-related instructions.
Stress Evaluation
- Evaluate stressors and coping mechanisms.
- Use open-ended questions about the cause and amount of stressful feelings.
Activity and Exercise Assessment
- Ask the client to describe their typical day.
- Mobility aids: cane, walker, or prosthesis?
- Ability to navigate safely in their home and environment?
- Frequency and type of exercise?
- Leisure activities?
ADLs definition
- Activities of Daily Living
Sleep Assessment
- Describe sleep pattern.
- Use of sleep aids: frequency and effectiveness?
- Daytime naps?
- Feeling rested after a night’s sleep?
Spirituality Assessment
- Spirituality is assessed using the FICA acronym
- F - Faith: spiritual traditions followed?
- I - Influence: faith or spirituality guides health choices and practices?
- C - Community: participation in a religious or spiritual community?
- A - Address: religious preferences that need to be addressed?
Substance Use Assessment
- Alcohol Use:
- Patterns of alcohol consumption
- How often, how much, and when last drink was
- Guilt about drinking?
- Tobacco/Nicotine Use:
- Type of tobacco used
- Amount smoked in a day
- Length of time smoking/chewing
- Former smokers: record how long ago they quit
- Recreational Drug Use:
- Use of illicit drugs or prescription medications for nontherapeutic reasons: frequency and dosage
External Factors Considerations
- Occupational Health
- Exposure to health hazards?
- Risk for injury?
- Use of protective equipment?
- Feelings of work stress and interactions with coworkers?
- Employer programs?
- Living Environment:
- Working smoke & carbon monoxide detectors?
- Fall hazards: dimly lit areas or throw rugs?
- Heating and cooling systems?
- Exposure to lead paint or asbestos?
- Access to fresh water and sewage services?
- Neighborhood safety?
- Fresh food, transportation, and healthcare access?
- Air or Noise pollution?
- Relationships
- Interactions with family and friends, characterizing
- Potential negative or positive social relationships
- Maltreatment:
- Screen all clients for partner violence or adult abuse
- Ask additional questions to determine adult maltreatment or human trafficking
Conclusion
- The findings should be documented clearly, concisely, and factually in the medical record.
- Facilitate sharing with healthcare team members and identify areas needing follow-up or education.
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Description
Your goal in conducting a health history interview is to have a structured conversation with the client. You will gather pertinent details about their background and current medical status. Your work provides the context in which the client receives personalized health care.
