2 Health History
Learning Objectives
- Describe the purpose of a health history
- Enumerate the components of a health history.
- Discuss how culture, age and ethnicity influence obtaining a health history.
- Demonstrates therapeutic communication when obtaining a health history.
- Obtain a comprehensive health history
- Document the results of the health history
Overview of this chapter
This chapter presents the importance of a health history as a component of health assessment and the value of a health history obtained from the perspective of a nurse. This chapter will provide information on components of a health history, considerations in obtaining a health history and documentation.
Health History
Purpose
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).
Subjective Data
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. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012). The health history is the subjective data collection portion of the health assessment.
Components of a Health History
The health history obtained by nurses is framed from holistic perspectives of all factors that contributes to the patient’s current health status. The most common way of obtaining information is through an interview, primarily of the patient. When the patient is unable to provide information for various reasons, the nurse may obtain it from secondary sources.
Knowledge Check:
The checklist below provides steps of obtaining a nursing history based that reflects its components such as biographical data, reason for seeking care, history of present illness, past health history, family history, functional assessment, developmental functions and cultural assessment. Each healthcare facility will have electronic and/or paper forms based on these components.
Disclaimer: Always review and follow your hospital policy regarding th