{"id":305,"date":"2015-02-17T19:39:48","date_gmt":"2015-02-17T19:39:48","guid":{"rendered":"http:\/\/opentextbc.ca\/clinicalskills\/?post_type=chapter&p=305"},"modified":"2021-05-20T19:37:34","modified_gmt":"2021-05-20T19:37:34","slug":"2-4-health-history-subjective-assessment","status":"publish","type":"chapter","link":"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/2-4-health-history-subjective-assessment\/","title":{"raw":"2.4 Health History","rendered":"2.4 Health History"},"content":{"raw":"The purpose of obtaining a\u00a0health history is to gather\u00a0subjective data from the patient\u00a0and\/or the patient's family\u00a0so that the health care team\u00a0and the patient can collaboratively create a plan that will\u00a0promote health, address\u00a0acute health problems, and minimize chronic health conditions. The health history is typically\u00a0done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013).\r\n\r\nData gathered may be subjective or objective in nature.\u00a0Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al.,\u00a02012).\r\n\r\nThe hospital\u00a0will have a form with assessment questions similar to the ones listed in Checklist 16.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
<\/a>Checklist 16: Health History Checklist<\/caption>\r\n
\r\n
Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/h5>\r\n<\/td>\r\n<\/tr>\r\n
\r\n

Steps<\/h4>\r\n<\/td>\r\n

\r\n

Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

Determine the following:\r\n\r\n1. Biographical data<\/td>\r\n\r\n
    \r\n \t
  • Source of history<\/li>\r\n \t
  • Name<\/li>\r\n \t
  • Age<\/li>\r\n \t
  • Occupation (past or present)<\/li>\r\n \t
  • Marital status\/living arrangement<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
2. Reason for seeking care and history of present health concern<\/td>\r\n\r\n
    \r\n \t
  • Chief complaint<\/li>\r\n \t
  • Onset of present health concern<\/li>\r\n \t
  • Duration<\/li>\r\n \t
  • Course of the health concern<\/li>\r\n \t
  • Signs, symptoms, and related problems<\/li>\r\n \t
  • Medications or treatments used (ask how effective they were)<\/li>\r\n \t
  • What aggravates this health concern<\/li>\r\n \t
  • What alleviates the symptoms<\/li>\r\n \t
  • What caused the health concern to occur<\/li>\r\n \t
  • Related health concerns<\/li>\r\n \t
  • How the concern has affected life and daily activities<\/li>\r\n \t
  • Previous history and episodes of this condition<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
3. Past health history<\/td>\r\n\r\n
    \r\n \t
  • Allergies (reaction)<\/li>\r\n \t
  • Serious or chronic illness<\/li>\r\n \t
  • Recent hospitalizations<\/li>\r\n \t
  • Recent surgical procedures<\/li>\r\n \t
  • Emotional or psychiatric problems (if pertinent)<\/li>\r\n \t
  • Current medications: prescriptions, over\u00ad-the\u00ad-counter, herbal remedies<\/li>\r\n \t
  • Drug\/alcohol consumption<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
4. Family history<\/td>\r\n\r\n
    \r\n \t
  • Pertinent health status of family members<\/li>\r\n \t
  • Pertinent family history of heart disease, lung disease, cancer, hypertension, diabetes, tuberculosis, arthritis, neurological disease, obesity, mental illness, genetic disorders<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
5.\u00a0Functional assessment (including activities of daily living)<\/td>\r\n\r\n
    \r\n \t
  • Activity\/exercise, leisure and recreational activities (assess for falls risk)<\/li>\r\n \t
  • Sleep\/rest<\/li>\r\n \t
  • Nutrition\/elimination<\/li>\r\n \t
  • Interpersonal relationships\/resources<\/li>\r\n \t
  • Coping and stress management<\/li>\r\n \t
  • Occupational\/environmental hazards<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
6.\u00a0Developmental tasks<\/td>\r\n\r\n
    \r\n \t
  • Current significant physical and psychosocial changes\/issues<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
7. Cultural assessment<\/td>\r\n\r\n
    \r\n \t
  • Cultural\/health-related beliefs and practices<\/li>\r\n \t
  • Nutritional considerations related to culture<\/li>\r\n \t
  • Social and community considerations<\/li>\r\n \t
  • Religious affiliation\/spiritual beliefs and\/or practices<\/li>\r\n \t
  • Language\/communication<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
Data source:\u00a0Assessment Skill Checklists, 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n
\r\n

Critical Thinking Exercises<\/p>\r\n\r\n<\/header>\r\n

\r\n
    \r\n \t
  1. You are taking a health history. Why is it important for you to obtain a complete description of the patient's\u00a0present illness?<\/li>\r\n \t
  2. You are taking a health history. What is one reason it is important for you to obtain a complete description of the patient's lifestyle and\u00a0exercise habits?<\/li>\r\n<\/ol>\r\n<\/div>\r\n<\/div>","rendered":"

    The purpose of obtaining a\u00a0health history is to gather\u00a0subjective data from the patient\u00a0and\/or the patient’s family\u00a0so that the health care team\u00a0and the patient can collaboratively create a plan that will\u00a0promote health, address\u00a0acute health problems, and minimize chronic health conditions. The health history is typically\u00a0done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013).<\/p>\n

    Data gathered may be subjective or objective in nature.\u00a0Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al.,\u00a02012).<\/p>\n

    The hospital\u00a0will have a form with assessment questions similar to the ones listed in Checklist 16.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n
    <\/a>Checklist 16: Health History Checklist<\/caption>\n
    \n
    Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/h5>\n<\/td>\n<\/tr>\n
    \n

    Steps<\/h4>\n<\/td>\n

    		\n

    Additional Information<\/h4>\n<\/td>\n<\/tr>\n

    Determine the following:<\/p>\n

    1. Biographical data<\/td>\n

    		\n
      \n
    • Source of history<\/li>\n
    • Name<\/li>\n
    • Age<\/li>\n
    • Occupation (past or present)<\/li>\n
    • Marital status\/living arrangement<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    2. Reason for seeking care and history of present health concern<\/td>\n\n
      \n
    • Chief complaint<\/li>\n
    • Onset of present health concern<\/li>\n
    • Duration<\/li>\n
    • Course of the health concern<\/li>\n
    • Signs, symptoms, and related problems<\/li>\n
    • Medications or treatments used (ask how effective they were)<\/li>\n
    • What aggravates this health concern<\/li>\n
    • What alleviates the symptoms<\/li>\n
    • What caused the health concern to occur<\/li>\n
    • Related health concerns<\/li>\n
    • How the concern has affected life and daily activities<\/li>\n
    • Previous history and episodes of this condition<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    3. Past health history<\/td>\n\n
      \n
    • Allergies (reaction)<\/li>\n
    • Serious or chronic illness<\/li>\n
    • Recent hospitalizations<\/li>\n
    • Recent surgical procedures<\/li>\n
    • Emotional or psychiatric problems (if pertinent)<\/li>\n
    • Current medications: prescriptions, over\u00ad-the\u00ad-counter, herbal remedies<\/li>\n
    • Drug\/alcohol consumption<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    4. Family history<\/td>\n\n
      \n
    • Pertinent health status of family members<\/li>\n
    • Pertinent family history of heart disease, lung disease, cancer, hypertension, diabetes, tuberculosis, arthritis, neurological disease, obesity, mental illness, genetic disorders<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    5.\u00a0Functional assessment (including activities of daily living)<\/td>\n\n
      \n
    • Activity\/exercise, leisure and recreational activities (assess for falls risk)<\/li>\n
    • Sleep\/rest<\/li>\n
    • Nutrition\/elimination<\/li>\n
    • Interpersonal relationships\/resources<\/li>\n
    • Coping and stress management<\/li>\n
    • Occupational\/environmental hazards<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    6.\u00a0Developmental tasks<\/td>\n\n
      \n
    • Current significant physical and psychosocial changes\/issues<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    7. Cultural assessment<\/td>\n\n
      \n
    • Cultural\/health-related beliefs and practices<\/li>\n
    • Nutritional considerations related to culture<\/li>\n
    • Social and community considerations<\/li>\n
    • Religious affiliation\/spiritual beliefs and\/or practices<\/li>\n
    • Language\/communication<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Data source:\u00a0Assessment Skill Checklists, 2014<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
    \n
    \n

    Critical Thinking Exercises<\/p>\n<\/header>\n

    \n
      \n
    1. You are taking a health history. Why is it important for you to obtain a complete description of the patient’s\u00a0present illness?<\/li>\n
    2. You are taking a health history. What is one reason it is important for you to obtain a complete description of the patient’s lifestyle and\u00a0exercise habits?<\/li>\n<\/ol>\n<\/div>\n<\/div>\n","protected":false},"author":5,"menu_order":4,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-305","chapter","type-chapter","status-publish","hentry"],"part":253,"_links":{"self":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/305","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/users\/5"}],"version-history":[{"count":25,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/305\/revisions"}],"predecessor-version":[{"id":10112,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/305\/revisions\/10112"}],"part":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/parts\/253"}],"metadata":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/305\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/media?parent=305"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapter-type?post=305"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/contributor?post=305"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/license?post=305"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}