Questions and Answers
What is the purpose of collecting the complete health history? (Select all that apply)
Is there any objective data included in the health history?
False
In what order is the health history organized?
- Biographical data, 2. Reason for seeking care (CC), 3. Present health status (HPI), 4. Previous medical history, 5. Family history, 6. Personal and social history, 7. Review of systems (ROS), 8. Problem list
How should the nurse obtain information on the patient's present health status?
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What is included in the previous medical history section of the health history?
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What is included in the biographical data section of the health history?
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What may the chief complaint section focus on?
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What does the chief complaint section include?
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How should the chief complaint section be handled for clinic patients?
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What should be included in the present health status section for a well patient?
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What should be included in the present health status section for an ill patient?
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What does the PQRSTU mnemonic stand for?
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How should the nurse address the patient's perception of her present health status?
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What questions should the nurse ask when completing a past history before a symptom analysis?
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What mnemonic should be used to do a symptom analysis in the HPI section, and what does it stand for?
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What should the nurse ask regarding the O in the OLD CART mnemonic?
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What should the nurse ask regarding the L in the OLD CART mnemonic?
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What should the nurse ask regarding the D in the OLD CART mnemonic?
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What should the nurse ask regarding the C in the OLD CART mnemonic?
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What should the nurse ask regarding the A in the OLD CART mnemonic?
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What should the nurse ask regarding the R in the OLD CART mnemonic?
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What should the nurse ask regarding the T in the OLD CART mnemonic?
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What is the importance of the past health history or past medical history (PMH) section?
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Study Notes
Health History Collection
- Collecting a complete health history establishes a subjective database essential for diagnosis and problem list development.
- Objective data is not included in the health history.
Health History Organization
- Organized in a specific sequence: biographical data, chief complaint, present health status, previous medical history, family history, personal/social history, review of systems, and problem list.
Chief Complaint
- Captures patient's primary reason for seeking care, which could relate to illness or wellness (e.g., routine check-up).
- The chief complaint section includes a concise statement of the problem and its duration (e.g., "I have chest pain when smoking").
Present Health Status
- For well patients, the section should provide a brief overview of their general health.
- For ill patients, it requires a symptom analysis detailing the characteristics of their condition.
Mnemonics for Symptom Analysis
- OLD CART is utilized for analyzing present health status:
- O: Onset
- L: Location
- D: Duration
- C: Character
- A: Aggravating/associated factors
- R: Relieving factors
- T: Treatment details
- PQRSTU is another mnemonic focusing on the provocative, quality, region, severity, timing, and understanding patient perception.
Patient Perception and History
- Nurses should explore the patient's perception of their health, including concerns and interpretations of their symptoms.
- Past history questions should address previous symptoms, diagnostic tests, and treatment efficacy.
Biographical Data Section
- Includes crucial personal information such as name, date of birth, birthplace, sex, marital status, race, ethnicity, religion, languages spoken, education level, occupation, health insurance, and reliability of the information provided.
Previous Medical History
- Encompasses childhood illnesses, serious/chronic illnesses, hospitalizations, surgeries, blood transfusions, obstetric history, immunizations, allergies, current medications, and screening tests.
Gathering Information on Symptoms
- For each aspect of the OLD CART mnemonic, specific inquiries should be made to pinpoint symptom details:
- Onset (O): Inquire about the start time, suddenness, and any predisposing factors.
- Location (L): Have the patient indicate the location and whether pain radiates.
- Duration (D): Ask about the typical length and frequency of symptoms, noting if they are constant or intermittent.
- Character (C): Gather detailed descriptions regarding the quality and severity of symptoms.
- Aggravating/Associated (A): Determine what worsens the symptoms and identify any secondary symptoms.
- Relieving (R): Explore what alleviates the symptoms.
- Treatment (T): Discuss any treatments attempted and their efficacy.
Importance of Past Medical History
- The past health history can significantly influence the patient's current health status and their responses to illness.
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Description
Test your knowledge on the crucial aspects of health history collection with these flashcards. Each card highlights key concepts essential for understanding the purpose and organization of health histories. Perfect for nursing and medical students preparing for clinical practice.