Authors: Lena Choudhary/ Raquel Bertiz
Objectives:
At the end of this chapter, the learner will:
1. Enumerate the components of a health history.
2. Describe how the nursing process guides the structure of a health history.
3. Discuss how culture, age and ethnicity influence obtaining a health history.
4. Demonstrates therapeutic communication when obtaining a health history.
5. Obtain a comprehensive health history
6. Document the results of the health history
Health History: An Overview
The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013).
Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history.
The hospital will have a form with assessment questions similar to the ones listed in the checklist below:
Oftentimes, a health history obtained by nurses is called a nursing history. A nursing history is approached from a holistic perspective. One’s health is affected by and affects their emotions, social interactions and support systems, genetics as seen in family members’ health and the patient’s health, past medical history and surgical history, behaviors such as eating, exercising, ingestion of non food items (smoking, drugs), sexual activity, work and home environment such as air quality, pets, abuse.
Therefore, in order to best address the needs of the patient, the nurse must collect information in all the dimensions of a patient’s health.
Components of a Health History
The components of a health history include:
I. Biographic data, if not yet available during initial patient interactions with other personnel, such as:
- age
- gender
- address
- DOB (date of birth)
- race
- religion
- occupation
- marital status
II. Reason for seeking help (also known as chief complaint):
This is a collection of information related to the chief complaint and is usually self-reported by patient. In instances when the patient may not be a reliable historian, in the case of a child, or an adult person with impaired verbal communication or impaired reasoning, a family member or a significant other maybe the source of this history data. The mnemonics OLDCARTS is usually used as guide to gather details of the chief complaint as reported by the patient or a reliable historian.
•O refers to o