6) THE COMPLETE HEALTH HISTORY

6) THE COMPLETE HEALTH HISTORY - 6) THE COMPLETE HEALTH...

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6) THE COMPLETE HEALTH HISTORY L. Meneghini RN MSN
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The Complete Health History Purpose: Collect subjective and objective data: What the patient states and what you see. Describes the patient as a whole and also how they interact It affirms what a person is doing right Records strengths and coping skills It contains chronological health problems Meet “Marley” ----- > (Submitted by Alisha Kats)
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The Complete Health History It records ways to respond to illnesses It is a screening tool for abnormal findings It is sequential and contains: Biographical data Reason for seeking care Present health history of present illness
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The Complete Health History Family history Review of systems Functional assessment or activities of daily living (ADL’s) Past history
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The Health History-The Adult Biographical Data: Name, address, phone number, occupation ,current or usual illnesses. Source of History: who furnishes information, how reliable is the information and are there any special circumstances, such as the use of an interpreter Reliability is a key
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Health History Reason for Seeking Care : A brief, spontaneous statement made by the patient. i.e.; “I have a sore throat” or “I need a physical for work” “chest pain for 2 hours…” Present Health or History of Present Illness: Collect all data first; do not add your own opinions. The data should contain eight critical characteristics:
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Past Health Past Health History: A narrative summary is needed for each Childhood Illness: Inquire about usual childhood immunizations, usual illnesses Accidents or injuries : M.V.A.’s, fractures, Serious/ Chronic Illnesses: DM, HTN, heart disease, sickle cell etc Hospitalizations : Reason, name of hospital, how treated, how long and by whom. Operations: Type, name of surgeon, name of hospital, how long.
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Past Health OB history : Para, Gravida, pre-term, AB’s, course of pregnancies, sex, wt. Post-partum course. Immunizations:
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This note was uploaded on 05/31/2011 for the course NUR 326 taught by Professor Meneghini during the Fall '10 term at St. Xavier.

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6) THE COMPLETE HEALTH HISTORY - 6) THE COMPLETE HEALTH...

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