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Health history sequence

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1. biographic data 2. reason for seeking care 3. present health or history of present illness 4. past history 5. family history 6. review of systems 7. functional assessment or activities of daily living (ADLs)

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Biographic data

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Includes name, address, phone number, age and birth date, birthplace, gender, marital status, race, ethnic origin, and occupation.

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Reason for seeking care

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A brief, spontaneous statement in the person's own words that describes the reason for the visit. It states one (possibly two) symptoms or signs and their duration.

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Present health or history of present illness

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For the well person, it's a short statement about the general state of health. For the ill person, it's a chronologic record of the reason for seeking care, from the time the symptom started until now.

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Past health

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Important because they may have effects on the current health state. Includes childhood illnesses, accidents or injuries, serious or chronic illnesses, hospitalizations, operations, obstetric history, immunizations, last exam date, allergies, and current medications.

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Family history

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Highlights diseases and conditions for which a particular patient may be at increased risk for.

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Review of systems

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Purpose of this is to evaluate past and present health state of each body system, to double-check in case any significant data was omitted, and to evaluate health promotion practices.The order of the examination of body systems is roughly head-to-toe.

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Functional assessment

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Measures a person's self-care ability in the areas of general physical health or absence of illness, ADLs, and in IADLs (instrumental activities of daily living).

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Symptom

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A subjective sensation that the person feels from the disorder.

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Sign

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An objective abnormality that you as the examiner could detect on physical examination or in laboratory reports.

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8 critical characteristics of a symptom

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-location -character or quality -quantity or severity -timing -setting -aggravating or relieving factors -associated factors -patient's perception

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PQRSTU mnemonic for symptoms

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P: provocative or palliative Q: quality or quantity R: region or radiation S: severity scale T: timing U: understand patient's perception

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How to document allergies

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Note both the allergen (medication, food, or contact agent) and the reaction (rash, itching, runny nose, watery eyes).

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Documenting medication use in older adults

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For each medication, record the name, purpose, and daily schedule. Does it work? Are there any side effects?

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Chapter 4: The Complete Health History – Flashcards

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