Final health history
comprehensive guide with
questions and verified answers
Explain a Complete health history. - ANSWER Appropriate for
patients that are new to the health care provider. Consists of
open-ended questions, and follow-up history is important. This
is a detailed assessment that allows the nurse to get to know the
patient's past, present, and possible future health problems.
Remember that a complete history is repetitive in questioning in
order to trigger the patient's.memory or help the patient
recognize the importance of data not shared.Complete Health
History - Identifying Data - ANSWER age, date of birth, gender,
occupation, marital or relationship status
List components of a Complete health history - ANSWER
Identifying Data, source of history and reliability, chief
complaints, history of present illness, Past History, Family
History,
Source of History and Reliability - ANSWER Usually the
source of history is the patient, but can be a family member or
friend, letter of referral, or the medical record.
1
,What is an Episodic or Focused health history? - ANSWER
Appropriate when the patient's is known to the nurse. Here the
nurse focuses on gathering information about the patient's
problem. Based on this information, along with symptoms, age,
and history will determine the extent of the physical
examination to perform.
What is a follow-up history? - ANSWER It is a form of a
focused assessment. Only this time the patient is returning to
have the problem or treatment re-evaluated. Follow up history
can also occur be done by a second shift nurse that is following
up on a problem from an earlier shift.
What is an emergency history? - ANSWER Focuses on the
ABC's. Airway, Breathing, and Circulation. Focuses on a
systemic priority of the emergency situation.
Chief Complaints - CC - ANSWER The one or more symptoms
or concerns causing the patient to seek care.
History of Present Illness - ANSWER Amplifies the Chief
Complaint, and describes how each symptom developed.
Includes patient's thoughts and feelings about the illness. Pulls
in relevant portions of the Review Systems, called pertinent
positives and negatives. May include medications, allergies, and
smoking or alcohol habits which are relevant to the present
2
,illness. Remember to start with broad questions. If there is a
present problem then use Old Cart as follow up questions.
Past History - ANSWER Begin with asking, "How has your
health been in the past?" List childhood illnesses, adult illnesses
with dates for at least three categories, such as medical, surgical,
and psychiatric. Include immunization dates, screening tests,
lifestyle issues, and home safety. Include any risk factors.
For children ask for birth history, and Growth and Development.
Family History - ANSWER Attain specific family history of
disease, such as the age, health, cause of death if relevant or
immediate family members. Record using a genogram.
Review of Systems - ANSWER Document presence or absence
of common symptoms related to each major body system.
Example for integumentary would be, have you had any recent
rashes, lumps, sores, itching, dryness, changes in color, changed
in hair or nails, changes in size or color of moles.
Health Patterns - ANSWER Documents personal and social
history
Student: What are my objectives in this assessment? - ANSWER
Diana Shadow: A health history requires you to ask questions
related to Ms. Jones' past and present health, from her current
3
, foot wound to her pre-existing conditions. You will also want to
review Ms. Jones' systems, psychosocial history, and family
medical history. These assessments together will give you a
comprehensive picture of Ms. Jones' overall health. If you
discover any disease states, ask about symptoms and the
patient's experiences of them. Your questioning should cover a
broad array of the symptoms' characteristics. Throughout the
conversation, you should educate and empathize with Ms. Jones
when appropriate to increase her health literacy and sense of
well-being. Regardless of whether you have assessed Ms. Jones
previously, ask all questions that are necessary for obtaining a
complete health history. While you should communicate with
patients using accessible, everyday language, it is standard
practice to use professional medical terminology everywhere
else, such as in documenting physical findings and nursing
notes. You may complete the exam activities in any order and
move between them as needed. After obtaining Ms. Jones' health
history, you will complete an information processing activity.
You will identify and prioritize diagnoses, then create a plan to
address the identified diagnoses.
A nurse is preparing to collect a health history from a client.
Which of the following should the nurse plan to assess as a
component of a functional assessment? (select all that apply)
A. the reason that the client is seeking health care
B. if the client is experiencing abuse or human trafficking
4
comprehensive guide with
questions and verified answers
Explain a Complete health history. - ANSWER Appropriate for
patients that are new to the health care provider. Consists of
open-ended questions, and follow-up history is important. This
is a detailed assessment that allows the nurse to get to know the
patient's past, present, and possible future health problems.
Remember that a complete history is repetitive in questioning in
order to trigger the patient's.memory or help the patient
recognize the importance of data not shared.Complete Health
History - Identifying Data - ANSWER age, date of birth, gender,
occupation, marital or relationship status
List components of a Complete health history - ANSWER
Identifying Data, source of history and reliability, chief
complaints, history of present illness, Past History, Family
History,
Source of History and Reliability - ANSWER Usually the
source of history is the patient, but can be a family member or
friend, letter of referral, or the medical record.
1
,What is an Episodic or Focused health history? - ANSWER
Appropriate when the patient's is known to the nurse. Here the
nurse focuses on gathering information about the patient's
problem. Based on this information, along with symptoms, age,
and history will determine the extent of the physical
examination to perform.
What is a follow-up history? - ANSWER It is a form of a
focused assessment. Only this time the patient is returning to
have the problem or treatment re-evaluated. Follow up history
can also occur be done by a second shift nurse that is following
up on a problem from an earlier shift.
What is an emergency history? - ANSWER Focuses on the
ABC's. Airway, Breathing, and Circulation. Focuses on a
systemic priority of the emergency situation.
Chief Complaints - CC - ANSWER The one or more symptoms
or concerns causing the patient to seek care.
History of Present Illness - ANSWER Amplifies the Chief
Complaint, and describes how each symptom developed.
Includes patient's thoughts and feelings about the illness. Pulls
in relevant portions of the Review Systems, called pertinent
positives and negatives. May include medications, allergies, and
smoking or alcohol habits which are relevant to the present
2
,illness. Remember to start with broad questions. If there is a
present problem then use Old Cart as follow up questions.
Past History - ANSWER Begin with asking, "How has your
health been in the past?" List childhood illnesses, adult illnesses
with dates for at least three categories, such as medical, surgical,
and psychiatric. Include immunization dates, screening tests,
lifestyle issues, and home safety. Include any risk factors.
For children ask for birth history, and Growth and Development.
Family History - ANSWER Attain specific family history of
disease, such as the age, health, cause of death if relevant or
immediate family members. Record using a genogram.
Review of Systems - ANSWER Document presence or absence
of common symptoms related to each major body system.
Example for integumentary would be, have you had any recent
rashes, lumps, sores, itching, dryness, changes in color, changed
in hair or nails, changes in size or color of moles.
Health Patterns - ANSWER Documents personal and social
history
Student: What are my objectives in this assessment? - ANSWER
Diana Shadow: A health history requires you to ask questions
related to Ms. Jones' past and present health, from her current
3
, foot wound to her pre-existing conditions. You will also want to
review Ms. Jones' systems, psychosocial history, and family
medical history. These assessments together will give you a
comprehensive picture of Ms. Jones' overall health. If you
discover any disease states, ask about symptoms and the
patient's experiences of them. Your questioning should cover a
broad array of the symptoms' characteristics. Throughout the
conversation, you should educate and empathize with Ms. Jones
when appropriate to increase her health literacy and sense of
well-being. Regardless of whether you have assessed Ms. Jones
previously, ask all questions that are necessary for obtaining a
complete health history. While you should communicate with
patients using accessible, everyday language, it is standard
practice to use professional medical terminology everywhere
else, such as in documenting physical findings and nursing
notes. You may complete the exam activities in any order and
move between them as needed. After obtaining Ms. Jones' health
history, you will complete an information processing activity.
You will identify and prioritize diagnoses, then create a plan to
address the identified diagnoses.
A nurse is preparing to collect a health history from a client.
Which of the following should the nurse plan to assess as a
component of a functional assessment? (select all that apply)
A. the reason that the client is seeking health care
B. if the client is experiencing abuse or human trafficking
4
