Ch. 2: Health History Flashcards
Used to encourage responses that are more than one or two words
open-ended questions
Useful in gathering specific data elements
closed-ended questions
Techniques that enhance data collection
active listening, facilitation, clarification, restatement, reflection, confrontation, interpretation, and summarizing
Barriers to obtaining adequate information include:
the use of medical terminology, expressing judgment, interrupting the patient, exhibiting an authoritarian approach, and asking “why” questions
Components of a comprehensive health history
biographic data, reason for seeking care, history of present illness, present health status, past medical history, family history, personal and psychosocial history, and review of systems
Also known as the chief complaint
the reason for seeking care, may be recorded in direct quotes
History of present illness should include
onset of symptoms, location and duration, characteristics and severity of symptoms, alleviating or aggravating factors, and attempts at self-treatment
Present health status should include
any health conditions; medications, including OTC; and allergies with type of reaction
Past health history should include
past and present illnesses, surgeries, hospitalizations, accidents, immunizations, screening examinations, and obstetric history
Family history should include
illnesses of genetic, familial, or environmental causes, should include at least two generations of blood relatives and the health status of the spouse and children
Personal and social history should include
the patient’s general feelings about his or her health, satisfaction with family and social relationships, diet and nutrition habits, functional ability, mental health, personal habits, health promotion activities, and environmental health and safety
A method of inquiring about the patient’s health status of body systems
review of systems
