NU 610 AHA Study Guide Module 2 | Herzing University

Chapter 2 – Interviewing and the Health History


 Establishes the clinician-patient relationship
 Identifies health concerns and risk factors
 Provides subjective data
 Guides the physical examination
 Builds clinical reasoning skills



Components of the Health History
1. Identifying Data Includes: Name, Age, Gender identity, Source and reliability, Date/time, Referral source
2. Chief Complaint (CC) Example: “I have had chest pain for 2 days” Main reason for visit, Recorded in patient’s own words
3. History of Present Illness (HPI) Uses chronological description of symptoms.
OLD CARTS Framework
Letter Meaning
O Onset
L Location
D Duration
C Characteristics
A Aggravating factors
R Relieving factors
T Timing
S Severity

4. Past Medical History Includes:


 Childhood illnesses
 Adult illnesses
 Hospitalizations
 Surgeries
 Obstetric history
 Psychiatric history
 Immunizations

5. Medications Include: Always assess: Dose, Frequency, Adherence, Side effects


 Prescription medications
 OTC medications
 Herbal supplements
 Vitamins
 Recreational substances

6. Allergies Document: Medication allergies, Food allergies, Environmental allergies, Type of reaction. Avoid writing “NKDA” without verification.

7. Family History Important for: Genetic risk assessment, Chronic disease prediction Assess:


 Hypertension
 Diabetes
 Cancer
 Mental illness
 Cardiovascular disease

8. Social History Assess:


 Occupation
 Education
 Living conditions
 Tobacco use
 Alcohol use
 Substance use
 Nutrition
 Exercise
 Sexual history
 Safety concerns

Therapeutic Communication Techniques
Effective Techniques
Open-ended questions
Active listening
Reflection

,Clarification
Empathy
Summarization

Nonverbal Communication Includes: Eye contact, Posture, Facial expression, Tone of voice, Therapeutic silence
Barriers to Communication


 Medical jargon
 Bias
 Interrupting
 Cultural differences
 Language barriers
 Anxiety
 Pain

Cultural Humility and Patient-Centered Care Key concepts:


 Respect patient beliefs
 Avoid assumptions
 Use interpreters appropriately
 Recognize social determinants of health
 Shared decision-making



Review of Systems (ROS) Systematic symptom review from head-to-toe. Purpose: Identify overlooked symptoms, Support differential diagnosis
Documentation Tips


 Accurate
 Concise
 Organized
 Avoid judgmental language
 Record pertinent positives and negatives



Chapter 3 – Mental Health, Behavior, and Psychosocial Assessment Mental Status Examination (MSE) Assesses:


 Appearance
 Behavior
 Speech
 Mood
 Affect
 Thought process
 Cognition
 Insight
 Judgment

Components of the Mental Status Exam Appearance Observe:


 Hygiene
 Dress
 Facial expression
 Eye contact

Behavior Assess:


 Agitation
 Cooperation
 Motor activity
 Psychomotor changes

Speech Evaluate:


 Rate
 Volume
 Fluency
 Articulation

Mood vs Affect

, Mood Affect
Patient’s internal emotional state Observable emotional expression

Thought Process Normal:


 Logical
 Goal-directed

Abnormal:


 Tangential
 Circumstantial
 Flight of ideas

Thought Content Assess for:


 Delusions
 Obsessions
 Suicidal ideation
 Hallucinations

Cognitive Assessment Orientation Assess:


 Person
 Place
 Time
 Situation

Memory
Type Description
Immediate Recall immediately
Recent Minutes to days
Remote Long-term memory

Attention and Concentration Tests:


 Serial 7s
 WORLD backwards

Screening Tools Depression PHQ-9 Screens for:


 Major depressive disorder
 Severity of depression



Anxiety GAD-7 Screens generalized anxiety disorder severity.
Substance Use CAGE Questionnaire Used for alcohol misuse screening.
SBIRT


 Screening
 Brief Intervention
 Referral to Treatment

Suicide Risk Assessment Assess:


 Ideation
 Plan
 Means
 Intent
 Previous attempts

Red flags:


 Hopelessness
 Isolation
 Sudden calmness after severe depression

Delirium vs Dementia vs Depression