updated
1. Biographic Data - name
-age
-gender
-relationship status
-ethnic origin
-occupation
-language
2. Reason for
Seek- ing Care Chief Complaint - brief statement in person's own words
3. History of Pre-
sent Illness P - provocation
(HPI)
Q - quality
R - region
S - severity
4. Past Medical T - time
His- tory (PMH)
the patient's diagnoses, past illnesses, medications, allergies, * if
allergies, what are the reactions?
5. Family History Genogram - highlights family members' diseases and conditions
-helps identify what conditions a patient is at risk for
6. Family History
- Genogram -genogram: graphiv family tree that uses symbols to depict the
gender, rela- tionship, and age of immediate blood relatives in at least
3 generations such as parents, grandparents, and siblings
-the health of close family members such as spouse or partner and
children are important
-record the medical condition of each relative and other significant health
7. Family History data such as age and cause of death, twinning, alcohol use
-
1/
21
,NURS 251 Exam #1 questions well answered
updated
-ask about coronary heart disease
Questions to Ask? - high blood pressure, stroke
2/
21
, NURS 251 Exam #1 questions well answered
updated
-diabetes
-obesity
-blood disorders
-cancer
-arthritis
-allergies
-allergies
-alcohol/drug use
-mental illness
8. Review of -evaluate past and present health state of each body system, double-check
Sys- tems signif- icant data, and to evaluate health promotion practices
-- include Mental Health, Sexual Health
-- if negative, document "denies"
-- write "presence" or "absence" or "denies" of all systems
-- Do Not record physical data
-Review of Systems:
-- skin - rash or lesion
-- head - headaches, head injury, dizziness
9. Functional As- -- eyes - earaches, infections
sessment -- respiratory - shortness of breath, history of lung disease (asthma)
-definition: measures a person's self-care ability in the areas of general
physical health
-assessing health patterns (i.e. diet, exercise, coping, sleep, nutrition etc.)
-assessment will provide data on the lifestyle and type of living
environment
*personal habits (tobacco, alcohol, drug screening)
*environmental hazards
*sociocultural
** interpersonal relationships
3/
21