HISTORY UPDATED ACTUAL QUESTIONS
AND CORRECT ANSWERS FULL SOLUTION
⩥ What can lead to inadequate patient care?
Answer: An incomplete history or poor documentation.
⩥ What type of data is focused on in health histories?
Answer: Subjective data reported by the patient.
⩥ What should be assessed regardless of the history type?
Answer: Current medications and allergies.
⩥ What is a complete health history best used for?
Answer: Most often at the first visit to gather a full, head-to-toe
subjective database.
⩥ When is an inventory history appropriate?
Answer: When a brief review is needed and full detail is not required.
⩥ What is the purpose of a problem-focused history?
Answer: To address an acute complaint in an established patient.
, ⩥ What does an interim history document?
Answer: Chronicles events since the last visit.
⩥ What is the structure of a comprehensive health history?
Answer: Identification, chief concern, history of present illness, past
medical history, family history, personal/social history, review of
systems.
⩥ What is included in the identification section of a health history?
Answer: Patient demographics and reliability of the history source.
⩥ How should the chief concern (CC) be documented?
Answer: In the patient's own words and placed in quotation marks.
⩥ What does the history of present illness (HPI) describe?
Answer: A chronological description of how the current illness
developed.
⩥ What are the core elements to document in HPI?
Answer: Location, quality/character, severity, duration, timing, context,
modifying factors, associated signs/symptoms.