NRSG 302 - Communication and Health History
questions and answers graded A+
common traps to avoid while taking a history (interview traps)
- false assurance
- unwanted advice
- authority
- avoidance language
- distancing
- too much personal information
- professional/medical terms
- leading/biased questions
- talking too much
- interrupting
- asking "why"
- rewording/paraphrasing (record whatever person says word for word)
health history interview format
1) introduction
2) working phase
3) closing
introduction of health history
- explain the purpose of health history (subjective data)
- uncomfortable questions
- therapeutic communication for collaboration
- nurses uses special techniques and communication skills
sources of history
, - patient (primary source)
- charts and family members (secondary sources --> if secondary, what were the
special circumstances?)
format of health history
- biographical data
- chief complaint (reason for seeking care)
- history of present illness (HPI)
- past medical history
- family history
- personal and social history
- review of systems (summarize symptoms of which systems are involved)
biographic data
name, address, phone number, age, birthdate, gender, marital status, race, ethic
origin, occupation, primary language, insurance
past medical history
- current medications and indications
- serious or chronic illnesses
- hospitalizations/injuries
- allergies
History of present illness (HPI)
OLDCARTS
Onset
Location
Duration
Characteristics (i.e. intensity, quality)
Aggravating factors
questions and answers graded A+
common traps to avoid while taking a history (interview traps)
- false assurance
- unwanted advice
- authority
- avoidance language
- distancing
- too much personal information
- professional/medical terms
- leading/biased questions
- talking too much
- interrupting
- asking "why"
- rewording/paraphrasing (record whatever person says word for word)
health history interview format
1) introduction
2) working phase
3) closing
introduction of health history
- explain the purpose of health history (subjective data)
- uncomfortable questions
- therapeutic communication for collaboration
- nurses uses special techniques and communication skills
sources of history
, - patient (primary source)
- charts and family members (secondary sources --> if secondary, what were the
special circumstances?)
format of health history
- biographical data
- chief complaint (reason for seeking care)
- history of present illness (HPI)
- past medical history
- family history
- personal and social history
- review of systems (summarize symptoms of which systems are involved)
biographic data
name, address, phone number, age, birthdate, gender, marital status, race, ethic
origin, occupation, primary language, insurance
past medical history
- current medications and indications
- serious or chronic illnesses
- hospitalizations/injuries
- allergies
History of present illness (HPI)
OLDCARTS
Onset
Location
Duration
Characteristics (i.e. intensity, quality)
Aggravating factors
