HEALTH HISTORY - TINA ACTIVITY DESCRIPTION VIDEO
JONES
The purpose of obtaining a health history is to gather
subjective data from the patient and/or their care partners to
collaboratively create a nursing care plan that will promote
health and maximize functioning.
Hi Ms. Jones. My name is [your name]
and i will be your nurse for today.
GREETING
What brings you to the hospital today?
HPI (History of Present
(Allow the patient to answer)
Illness)
START W/ OPEN-ENDED
QUESTIONS
I'm sorry your're in so much pain. I'm
EMPATHIZE - MAKE AN glad you're here so we can help you.
EMPATHETIC STATEMENT
(Helps to build rapport and
trust with the patient.)
Terms in this set (44)
1
,QUALIFY SYMPTOMS - Use O-L-D C-A-R-T-S acronym as a
GET MORE reminder of what to ask. O - Onset l -
INFORMATION ON Location D - Duration
CONDITION (I.E., INJURY) C - Characteristics
A - Aggravating Factors
R - Relieving Factors
T - Treatment
S - Severity
Can you rate your pain on a scale of 1 to
10?
PAIN LEVEL
ONSET
When did the pain start?
I'm sorry you're in so much pain. I will
get you pain medication as soon as
BRIEFLY EMPATHIZE possible.
AGAIN
LOCATION
Where is your wound?
2
, CONVERSATION HELP Use correct spelling and grammar.
Try not to use pronouns (e.g., he, she,
they, it).
Avoid medical jargon.
Provide clear context for your questions.
Avoid sentence fragments (e.g.
"last pap?")
Ask about one subject at a time.
Use the Educate and Empathize
tabs.
If you don't get an answer, try asking a
more broad question.
PAST MEDICAL HISTORY Preexisting medical condition
Prior hospitalizations
Medications
Allergies
Immunizations
Do you have any other medical
conditions?
PREEXISTING MEDICAL
CONDITIONS
When were you diagnosed with
diabetes?
How are you managing your diabetes?
MORE INFO ON PRE-
Do you take any diabetes medication?
EXISTING CONDITION(S)
Why did you stop taking your diabetes
medication?
Are you monitoring your blood glucose?
3
JONES
The purpose of obtaining a health history is to gather
subjective data from the patient and/or their care partners to
collaboratively create a nursing care plan that will promote
health and maximize functioning.
Hi Ms. Jones. My name is [your name]
and i will be your nurse for today.
GREETING
What brings you to the hospital today?
HPI (History of Present
(Allow the patient to answer)
Illness)
START W/ OPEN-ENDED
QUESTIONS
I'm sorry your're in so much pain. I'm
EMPATHIZE - MAKE AN glad you're here so we can help you.
EMPATHETIC STATEMENT
(Helps to build rapport and
trust with the patient.)
Terms in this set (44)
1
,QUALIFY SYMPTOMS - Use O-L-D C-A-R-T-S acronym as a
GET MORE reminder of what to ask. O - Onset l -
INFORMATION ON Location D - Duration
CONDITION (I.E., INJURY) C - Characteristics
A - Aggravating Factors
R - Relieving Factors
T - Treatment
S - Severity
Can you rate your pain on a scale of 1 to
10?
PAIN LEVEL
ONSET
When did the pain start?
I'm sorry you're in so much pain. I will
get you pain medication as soon as
BRIEFLY EMPATHIZE possible.
AGAIN
LOCATION
Where is your wound?
2
, CONVERSATION HELP Use correct spelling and grammar.
Try not to use pronouns (e.g., he, she,
they, it).
Avoid medical jargon.
Provide clear context for your questions.
Avoid sentence fragments (e.g.
"last pap?")
Ask about one subject at a time.
Use the Educate and Empathize
tabs.
If you don't get an answer, try asking a
more broad question.
PAST MEDICAL HISTORY Preexisting medical condition
Prior hospitalizations
Medications
Allergies
Immunizations
Do you have any other medical
conditions?
PREEXISTING MEDICAL
CONDITIONS
When were you diagnosed with
diabetes?
How are you managing your diabetes?
MORE INFO ON PRE-
Do you take any diabetes medication?
EXISTING CONDITION(S)
Why did you stop taking your diabetes
medication?
Are you monitoring your blood glucose?
3
