Copyright 2002, Delmar, A division of Thomson Learning Chapter 3 The Complete Health History Including Documentation

Copyright 2002, Delmar, A division of Thomson Learning

Chapter 3

The Complete Health History Including Documentation


Competencies State the purpose of the four

different types of health history and provide an example of when each is used.

Identify the components of the complete health history.

Describe how to assess the ten characteristics of a chief complaint.

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Competencies Diagram a patient’s genogram correctly. Demonstrate sensitivity to patients of

different races, religions, ethnic backgrounds, sexual orientations, and socioeconomic status when conducting a health history.

Conduct a complete health history on ill and well patients and record data.


Types of Health History Provides information on the

patient’s health status: social, emotional, physical, cultural, and spiritual identity

Complete health history Episodic health history Interval or follow-up health history Emergency health history


Identifying Information Included in Medical Record Patient name Address Occupation Insurance Phone number

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Identifying Information Included in Medical Record Usual source of health care Date of birth Birth place Emergency contact Social security number


Complete Health History Patient profile Reason for seeking health care

Chief complaint (CC) Sign Symptom

Present health and history of present illness (HPI)


Ten Characteristics of a Chief Complaint Location Radiation Quality Quantity Associated manifestations

Pertinent negatives

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Ten Characteristics ofa Chief Complaint Aggravating factors Alleviating factors Setting Timing Meaning and impact


Past Health History (PHH) Provides information on the

patient’s health status from birth to present

Medical history Chronic illness Episodic illness Sequelae

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Past Health History Surgical history

Major procedures Minor procedures Include year performed, hospital,

physician, sequelae

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Past Health History Medications

Prescription Over-the-counter Herbs Home remedies General questions

Dose Frequency Side effects Purpose

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Past Health History Communicable diseases

Infectious Pertussis Tuberculosis Hepatitis AIDS

Sexually transmitted Gonorrhea Syphilis Chlamydia Herpes

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Past Health History Allergies

Medications Food Animals Environment Symptoms Treatment Complications


Past Health History Injuries/accidents Special needs Blood transfusions

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Past Health History Childhood illnesses

Varicella Diptheria Measles, mumps, rubella Polio, rheumatic or scarlet fever

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Past Health History Immunizations: childhood

MMR Polio Smallpox DPT Haemophilus influenza b (Hib) Hepatitis B

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Past Health History Immunizations: adult

Varicella Hepatitis A Hepatitis B Influenza Tetanus Pneumococcal Lyme Meningococcal Last TB test (date and results)


Family Health History (FHH) Records the health status of the

patient and immediate blood relatives.

Contains age and health status of the patient, spouse, children, siblings, and the patient’s parents.

Document information in a genogram and in a list of familial diseases.


Social History (SH) Records information about the

patient’s lifestyle that may impact health

Tips for obtaining information Establish rapport Direct eye-contact Pose questions in a matter of fact tone Nonjudgmental demeanor Normalizing

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Social History Alcohol use

Thorough assessment to include: Quantity of alcohol consumed Frequency of consumption Age at first drink Pattern of consumption Length of time consuming current amount History of loss of consciousness or

blackouts


Social History Time of day when drinking occurs Drink alone or with others Drink and drive Self perception of drinking

CAGE questionnaire (Mayfield, McLeod & Hall, 1974) Have you ever felt you should cut

down on your alcohol intake?

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Social History Have people annoyed you by

criticizing your alcohol intake? Have you ever felt guilty about your

alcohol intake? Have you ever needed alcohol for an

eye-opener (morning consumption)? Tobacco use

Pack/year history Type of tobacco used

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Social History Age started to use tobacco Quantity used on daily basis Previous attempts to quit Self-perception of tobacco use Live or work with smoker

Drug use Prescription and over-the-counter

medications

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Social History Illegal and recreational drugs Same types of questions used for

determining alcohol use Sexual practices, specific questions Sexual orientation Past sexual practice Number of partners Birth control method

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Social History Measures to prevent exchange of

body fluids Presence of STDs Satisfaction with sexual

performance/needs Travel history Work environment

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Social History Home environment

Physical Psychosocial

Hobbies or leisure activities Stress Education Economic status

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Social History Military service Religion Ethnic background Roles/relationships Functional health assessment

Activities of daily living

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Social History Health maintenance activities

(HMA) Sleep Diet Exercise Stress management Use of safety devices Health check-ups


Review of Systems (ROS) Cephalo-caudal approach Questions

Sign/symptom related Disease related questions


Documentation Guidelines Ensure accuracy

Record information immediately upon completion of patient encounter

Correct patient record or chart Avoid distractions while documenting Proofread your entry for accuracy and

completeness

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Documentation Guidelines Date and time each entry Sign each entry with full legal name

and professional credentials Write legibly Use permanent ink (black preferred) Do not leave a space between

entries(continues)


Documentation Guidelines Use quotes to indicate direct patient

response Document in chronological order Document in complete but concise

manner using phrases and abbreviations as appropriate

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Documentation Guidelines Document telephone calls that relate

to the patient’s case Never correct another person’s entry Use a single line to cross out an

error, then date, time and sign correction

If it is not documented, it was not done


Assessment-Specific Documentation Guidelines Record pertinent positive and negative

assessment data Document any parts of the assessment that

are omitted or refused by the patient Avoid using judgmental language Avoid evaluative statements; cite specific

statements or actions you observe(continues)


Assessment-Specific Documentation Guidelines State time intervals precisely Use specific measurements Draw pictures when appropriate

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Assessment-Specific Documentation Guidelines Refer to findings using anatomic

landmarks Use the face of a clock to describe

findings that are in a circular pattern Document any change in the patient’s

condition during a visit or from previous visits

Describe what you observed, not what you did

Documents

Copyright 2002, Delmar, A division of Thomson Learning Chapter 3 The Complete Health History Including Documentation