Chapter 4 Complete Health History – Flashcards

patients name, DOB, occupation, primary language, and communication needs

to show who you received the data from, to judge reliability of the information, and in order to get the best communication out of the patient for accuracy

for a well person, note the general state of health... for an ill person, chronologically record reason for seeking care... Pay close attention to the mention of Sx then preform a sx analysis (OLDCARTS)

biographical data, source of info, reason for seeking care, present health or history of present illness, past health events, family history, review of systems, and functional assessment

evaluate past and present health state of each system, double check in case any information was overlooked or omitted, evaluate health promotion practices.

ask additional questions such as exploring changes in activities of daily living that may result from the aging process or chronic illness. Recognize positive health measures

Functional measurements of how much independence a person has such as baithing, dressing, toileting, eating, walking, laundry, cooking, shopping, housekeeping etc. observe and ask questions about self esteem, activity, sleep, nutrition, relationships, religion, coping, habits, alcohol, drugs, environment, partner violence and occupational health

1. physiological (breathing, food, water, sex, sleep, maintaining homeostasis) 2. Safety (security of body, employment, mortality, family health, property and resources) 3. Love/belonging (friendship, family, sexual intimacy) 4. Esteem (self esteem, confidence, achievement, respect of others, respect by others) 5. Self-actualization (mortality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts)