Health History (Hx) and Documentation PDF

2/4/24, 5:54 PM OneNote Interview, Health History(Hx) and Documentation. Tuesday, January 09, 2024 8:55 AM Key Concepts. Health History(Hx) : describe what you see. The purpose of the health history is to collect subjective data: what the patient says about himself, herself, or themselves. The histo...

2/4/24, 5:54 PM OneNote Interview, Health History(Hx) and Documentation. Tuesday, January 09, 2024 8:55 AM Key Concepts. Health History(Hx) : describe what you see. The purpose of the health history is to collect subjective data: what the patient says about himself, herself, or themselves. The history objective data from the physical examination and with laboratory studies to form the database Subjective data : information given by patient. The patient's perspective. Not to say if they are right or wrong> Use terms like patient states "….". Objective data : what the nurse observes or sees, hears, feels or smells about the patient, verifiable data, measurable. Health History Types (4) Complete health history : data collected in every single 12 categories, e.g a person is new to a hospital and all about the person's health has to be known Focused health history : focuses on only what the patient complains about or reason for seeking care. Emergency history : uses only yes/no answers. Urgent. Follow-up history : follow-up on an illness if it is getting better or not. Health History Categories (12) : 1. Biographical data: Key information that the nurse may gather or validate. Where you get their address, phone number, patient’s name, age and birthdate, birthplace, other recent gender identity, relationship status, and usual and current occupation or daily activity pattern, etc. 2. Source of Hx: Who is providing? What is relationship? Substitute Decision Maker is a legal position. Know source of information, may be the patient or family member. Get a trans members because they might interpret not translate. 3. Reason for seeking care (RSC): “Quote”, using patient’s words. Signs-Objective, Symptoms-Subjective. A symptom is a subjective sensation that the patient feels from the disorde abnormality that you as the examiner could detect on physical examination or in laboratory reports. ex : I am here today because I have this terrible cough. Onset :when and what happened. tell me more about and re-state what patient says. Ex: started 3 days ago after I was at a family gathering, lots of kids had runny noses. Palliative and provocative : what makes the symptoms better or worse. Ex: it gets worse when I lie down, it gets better when I use a humidifier and cough syrup Quality and quantity : describe your symptoms , also quantify pain like on a scale of 0-10. Ex : moderate amount with each cough. Radiation and Region : location and how it is shown. Ex: the cough is rattling , the cough is coming deep from my chest. Severity/ setting : where did it happen Time/pattern : is the pain constant or not, when did it start, what time of the day does it happen. Ex: I cough frequently. Understanding : patient's understanding of their illness, what do you think is wrong. Ex : I think I have a cold. Associated signs and symptoms : ex : green sputum, ask about pain scale , no nausea. 4. Current health history: For those who are well. Current health state 5. History of current illness: For those who are ill. Chronological record of RSC. Eight critical characteristics: L, R, S, S, A, A, T3, U (similar to OPQRSTU). Associated S&S. 6. Past health history: Complete OR relevant MUST ask for Allergies, Current Medications (Prescription (Rx), Over the Counter (OTC), Homeopathic/Herbal, Childhood illnesses, etc. 7. Family history: Ages and Health, Date of Death, Cause of Death. Relevant-shared illness related to RSC. 8. Review of systems (includes health promotion): The purposes of this section are to evaluate the past and current health state of each body system, to double-check in case any sig the Current Illness section, and to evaluate health promotion practices. The order of the examination of body systems is approximately head to toe. Each body system is reviewed reviewed based on RSC. 9. Functional assessment : In a functional assessment, you measure a patient’s self-care ability in the areas of general physical health or absence of illness; activities of daily living (AD toileting, eating, and walking; instrumental activities of daily living (IADLs), which are activities needed for independent living. Activities of daily living (ADL)/Instrumental activities spiritual belief etc. sensitive topics like alcohol absorption, drug abuse etc. Documentation: Legal Criteria, Standards, Processes Effective Interview Strategies Communication Excellence Privacy & Confidentiality : Safe space to conduct interview Not overheard by others( that is; closed door not just a curtain demarcation) Privacy: Information will be shared ONLY with those on the care team; e.g., Physician, pharmacist, administrative assistant (biographical data only), social work etc. Health History (check slides for image illustration) Outline components of the distinct ( X means it's included in the complete health history). Documentation Describe the legal guidelines for reporting & recording client assessments and care. Recording: All assessments obtained are to be recorded using the agency processes. Acceptable formats include narrative, pictorial, graphs. Format may be Electronic (Documentation may include declarations such as, WNL (within normal limits) checkbox), or paper form. Reporting: Abnormal findings may need to be verbally reported to most responsible provider (MD or NP) as well as documented. Some findings may need to be reported to the health care team and then involve reporting to police (bullet wounds), Children’s Aid Services (CAS). Documentation: Criteria CNO Standard Statements : the College of Nurses of Ontario make these set of rules on documentation. Communication: Nurses ensure that documentation presents an accurate, clear and comprehensive picture of the client’s needs, the nurse’s interventions and the client’s outcom Accountability: Nurses are accountable for ensuring their documentation of client care is accurate, timely and complete. Security: Nurses safeguard client health information by maintaining confidentiality and acting in accordance with information retention and destruction policies and procedures th the standard(s) and legislation. If you forget to document at the right time, you sign it late when you do remember to do it. CNO: Using abbreviations and symbols appropriately by ensuring that each has a distinct interpretation and appears in a list with full explanations approved by the organization or BP, Temp, SaO2, HR, RR. https://yuoffice-my.sharepoint.com/personal/ife20_yorku_ca/_layouts/15/Doc.aspx?sourcedoc={bf93dbc4-cdec-494f-8064-58e33247d86a}&action=edi… 1/3 2/4/24, 5:54 PM OneNote Interview. The interview is the first part of data collection. It entails the collection of subjective data Introductions: Hello, I am (First and Last name). I am a nursing student first year at York University. I am here today to conduct your health history interview, (consent) “is that ok f The Process of Communication: Examine cultural, social, & developmental considerations in interviewing Verbal and Non-verbal communication Recognizing Implicit Bias : stereotypes and prejudices that you may hold toward people without your conscious knowledge Attending to Power Differentials: You must continually assess how you may be using your power in relation to patients as you facilitate their access to the health care system Providing Inclusive Care to Sexual and Gender Diverse Communities: People who identify as a member of the 2SLGBTQI+ ∗ community face unique barriers when accessing health discrimination, and inequitable access to appropriate health care services Providing Culturally Safe and Inclusive Care for People Who Are Two-Spirit : Two-Spirit is a term that is used in some Indigenous communities and relates to cultural, spiritual, sexu Communication Skills : Cultivating the skills of relational practice during the interview involves particular communication skills. These skills include unconditional positive regard, e Techniques of communication: Introducing the interview, Working phase(open-ended and close-ended questions), termination phase. Developmental considerations. Infants: They are more comfortable when the caregiver is kept in view Preschoolers: Only the child’s own experience is relevant School-age children: Children of this age group have the verbal ability to add important data to the history. Interview the caregiver and child together, but when the child has a pre the child about it first and then gather data from the caregiver Youth: Youth aged 13 to 19 want to be adults, but they do not yet have the cognitive ability to achieve their goal. They are between two stages. Sometimes they are capable of ma they revert to childhood response patterns, especially in times of stress. Adults and Older adults: The interview may take longer with older adults because they have a longer story to tell. Supplement reading Interviewing CONSIDERATIONS 1. Patients With Communication Disabilities: Interviewing patients with visible and nonvisible speech, language, or hearing disability requires that nurses deeply consider the process appropriate tools for communication. 2. Patients Who Are Acutely Ill : An emergency necessitates your prompt action. You must combine interviewing with physical examination skills to determine lifesaving actions. 3. Patients Experiencing Effects of Substances: When interviewing a patient experiencing the effects of substances, ask simple, direct questions, and convey a nonjudgemental stance 4. Patients asking Personal Questions: You may supply brief information when you feel it is appropriate but be sensitive to the possibility that there may be a motive behind the pers loneliness or anxiety. Try directing your response back to the patient’s frame of reference. https://yuoffice-my.sharepoint.com/personal/ife20_yorku_ca/_layouts/15/Doc.aspx?sourcedoc={bf93dbc4-cdec-494f-8064-58e33247d86a}&action=edi… 2/3