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When obtaining a health history, care partners may contribute important information related to the health and needs of the patient. If data is gathered from someone other than the patient, the nurse should document where the information is obtained.
- 2021
Apr 30, 2024 · The primary goal of obtaining a medical history from the patient is to understand the patient's state of health and determine whether the history is related. The secondary goal is to gather information to prevent potential harm to the patient during treatment.
- 2024/04/30
- Introductory Information: Demographic and Biographic Data
- Main Health Needs
- The PQRSTU Mnemonic
- Current and Past Health
- Mental Health and Mental Illnesses
- Functional Health
- Preventive Treatments and Examinations
- Family Health
- Cultural Health
Name/contact information and emergency information 1. What is your full name? 2. What name do you prefer to be called by? 3. What is your address? 4. What is your phone number? 5. Who can we contact in an emergency? What is their relationship to you? What number can we reach them at? Birthdate and age 1. What is your birthdate? 2. What is your age?...
Presenting to a clinic or a hospital emergency or urgent care (first point of contact) 1. Tell me about what brought you here today. Probes 1. 1.1. Tell me more. 1.2. How is that affecting you? Already admitted, and you are starting your shift 1. Tell me about your main health concerns today. Probes 1. 1.1. Tell me more. 1.2. How is that affecting ...
Provocative 1. What makes your pain worse? Palliative 1. What makes your pain feel better? Quality 1. What does the pain feel like? Quantity 1. How bad is your pain? Region 1. Where do you feel the pain? 2. Point to where you feel the pain. Radiation 1. Does the pain move around? 2. Do you feel the pain elsewhere? Severity 1. How would you rate you...
Current health 1. Are there any other issues affecting your current health? Childhood illnesses 1. Tell me about any significant childhood illnesses that you had. 2. When did it occur? 3. How did it affect you? 4. How did it affect your day-to-day life? 5. Were you hospitalized? Where? How was it treated? 6. Who was the treating practitioner? 7. Di...
Mental health is an important part of our lives and so I ask all clients about their mental health and any concerns or illnesses they may have. Mental health 1. Tell me about your mental health. 2. Tell me about the stress in your life. 3. How does stress affect you? 4. How do you cope with this stress? (this may include positive or negative coping...
Nutrition 1. Tell me about your diet. 2. What foods do you eat? 3. What fluids do you drink? (Probe about caffeinated beverages, pop, and energy drinks.) 4. What have you consumed in the last 24 hours? Is this typical of your usual eating pattern? 5. Do you purchase and prepare your own meals? 6. Tell me about your appetite. Have you had any change...
Medications 1. Do you have the most current list of your medications? 2. Do you have your medications with you? (If not, you should ask them to list each medication they are prescribed and if they know, the dose and frequency.) 3. Can you tell me why you take this medication? 4. How long have you been taking this medication? 5. Do you take the medi...
Tell me about the health of your blood relatives.Have any of your blood relatives died?Tell me about the health status of those you live with.Have you been around anyone else who was sick recently (e.g., at work, at school, in a location that involved a close encounter such as a plane or an office)?I am interested in your cultural background as it relates to your health. Can you share with me what is important about your cultural background that will help me care for you?
Dec 28, 2023 · 10 Components Of Nursing Health History. 1. Biographical Data: A Snapshot of Identity. Name, age, gender, and contact information. Marital status, occupation, and religious preference. Healthcare coverage, insurance, and primary source of medical care.
When obtaining a health history, care partners may contribute important information related to the health and needs of the patient. If data is gathered from someone other than the patient, the nurse should document where the information is obtained.
The purpose of obtaining a health history is to gather subjective data from the patient and/or their care partners to collaboratively create a nursing care plan that will promote health and maximize functioning. A comprehensive health history is completed by a registered nurse and may not be delegated.
If signs are present, defer the health history and obtain emergency assistance per agency policy. Complete a health history interview, including the following components per your instructor’s instructions: Demographic and Biological Data; Reason for Seeking Health Care; Current and Past Medical History; Family History; Functional Health
