02 Sep Find a patient, such as a friend or family member, to conduct an entire health history interview. Use the Health History Guideline attatched to
- Find a patient, such as a friend or family member, to conduct an entire health history interview.
- Use the Health History Guideline attatched to gather patient information.
- Type the history data in a Word document.
- Your homework should have:
- factual information.
- Subjective, meaning that you are only to document what the patient tells you.
- Written professionally and concisely.
- Typed in APA style Links to an external site.format with title page, margins, page numbers, headings, subheadings, and citations.
Health History Guideline
NUR3069 Page 1 of 4
Use this guide to gather patient information for the Comprehensive Health History Assignment.
Subject Criteria Possible Points
Patient Demographics • Gender, age, ethnicity, and other social
demographics as indicated (self-pay, Insurance) 5
Chief Complaint
• In the patient's own words, describe one or more symptoms or concerns that cause the patient to seek care.
• Elaborate on the chief complaint; describe how each symptom developed.
• Include the patient's thoughts and feelings about the illness.
5
History of Present
Illness
• Appropriate dimensions of cardinal symptoms are listed (including location, severity, quality, setting, chronology, aggravating/alleviating, and associated manifestations)
• HPI narrative flows smoothly in a logical fashion
• For those students who favor mnemonics, the 8 dimensions of a medical problem can be easily recalled using OLD CARTS (Onset, Location/radiation, Duration, Character, Aggr avating factors, Relief factors, Timing, and Severity).
10
Past Medical History
• Lists childhood illnesses
• Lists adult illnesses with dates for at least three categories: medical, surgical, and psychiatric.
• Medication, Allergies
• List patient's health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety.
5
Current Health Status • Summary of general health status related to the
present illness. 5
Health History Guideline
NUR3069 Page 2 of 4
Family History
Narrative and
Genogram
https://genopro.com/geno
gram/medical/
• Outlines or diagrams of age and health or age and cause of death of siblings, parents, grandparents, and children.
• Documents the presence or absence of specific illnesses in the family (e.g., hypertension, coronary artery disease)
• The family pedigree shows at least three generations and involves standardized symbols, which mark individuals affected with a specific diagnosis to allow for easy identification.
10
Risk Assessment
Based on Family
History
• Family history of a known or suspected genetic condition
• Ethnic predisposition to certain genetic disorders
• Consanguinity (blood relationship of parents)
• Multiple affected family members with the same or related disorders
• Earlier than expected age of onset of disease
• Diagnosis in less-often-affected sex
10
Social History
• Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur?
• Do they drink alcohol? If so, how much per day and what type of drink?
• Any drug use, past or present, should be noted.
• Work, family, friends, community support systems,
5
Past Surgical History
• Were they ever operated on, even as a child?
• What year did this occur?
• Were there any complications?
5
Health History Guideline
NUR3069 Page 3 of 4
Sexual Activity
• Do they participate in intercourse? With persons of the same or opposite sex?
• Are they involved in a stable relationship?
• Do they use condoms or other means of birth control?
• If married? The health of the spouse? If divorced? Past sexually transmitted diseases?
• Do they have children? If so, are they healthy? Do they live with the patient?
5
Work/Hobbies/Other
• What sort of work does the patient do?
• Have they always done the same thing? Do they enjoy it?
• If retired, what do they do to stay busy? Any hobbies?
5
Review of Systems
(ROS)
• Document the presence or absence of common symptoms related to each central body system.
• Consider asking a series of questions going from "head to toe."
• The questions asked to reflect an array of standard and critical clinical conditions (heart disease, diabetes, arthritis) explicitly prompt the patient,
• Format o General/skin/sleep o HEENT o Respiratory o Cardiovascular o Musculoskeletal o Endocrine o Gastrointestinal and Urinary o Neuro/psych
10
Prevention and Health
Promotion
• List at least one prevention activity.
• List at least three health promotion recommendations.
10
Health History Guideline
NUR3069 Page 4 of 4
APA Guidelines &
Writing Style
• APA (title page, margins, page numbers, headings, subheadings, citations); spelling; writing straightforward, concise, and professional.
10
Total 100
