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 onset of the chief complaint and elicited by the nurse asking the patient when did symptom/s or chief complaint begin (i.e. two days ago)
•L refers to location and is obtained by asking the patient where in the body are they experiencing, or have experienced the symptoms as exactly as possible, and if applicable (i.e. lower left abdomen). Some chief complaints maybe so diffused or generalized that the patient may not be able to relate the exact location of the discomfort, pain or whatever symptom this maybe.
•D refers to duration; the nurse will need to ask how long does the symptom/s last or whether it is ongoing or intermittent ( I.e. it comes and goes)
•C pertains to characteristics; If it is about pain the nurse ask the patient ” How does it feel?” (i.e. Tight, stabbing, nagging, dull, itchy, or an appropriate question to allow the patient to describe the characteristics of the chief complaint
•A stands for aggravating and alleviating factors : what makes it feel better or worse? ( ie. Movement, photophobia)
•R refers to related symptoms: The nurse may ask the patient “Are you experiencing any other symptoms related to your first complaint?” (i.e. fever, nausea); “What else happens when you experience the chief complaint”?
•T is data collected around treatment that the patient may have attempted as the nurse may ask : “What have you tried so far to relieve the symptoms?” (i.e. OTC medications, heating pad)
•S refers to the severity of the chief complaint: If the chief complaint is pain, the nurse uses the pain scale by asking “On a scale of 0 to 10 with zero being no pain and 10 being the worst pain….” or in some non pain issues ” What is the size of the wound, or number of hives”?
III. Past medical history:
The nursing history will include obtaining the patient’s pat medical history. This is an important information that will provide a wholistic picture of the patient’s health and risk factors. This includes diseases or illness that the patient no longer suffers. It also includes past immunizations, annual physicals, dental and vision care. These may impact the patient’s present health, or the treatments that are safe to use for the current chief complaint. For example: a patient who has had a transplant will most likely always be on immunosuppressant drugs. This puts them at higher risk for infections. Another example:patients taking MAOI’s for mental health cannot take many other drugs that interfere or interact with the MAOIs.
IV. Past surgical history:
A past surgical procedure can impact the patient’s current health and chief complaint. For example: if the patient had a prior appendectomy or removal of a cancerous skin lesion
V. Past family history: What illnesses or disease processes have your genetically related family members suffered from. These could be inherited by the patient. For example: some forms of breast cancer can be inherited as well as diabetes.
VI. Social History
This component of the health history includes:
- current or past use of illicit drugs, tobacco and alcohol
- significant partners
- Support systems: Who do you go to when you are stressed and need help?
- Current work or academic life: the environment of these can impact the patient’s health (i.e. stress of nursing school, or airborne pollution from working in the coal mines)
- Mental health: present concerns of depression or anxiety
- Living conditions, or environment: who do you live with, where do you live (i.e. homeless shelter), do you feel safe with those you life with?
- Family planning: What do you do to prevent STI’s and pregnancy?
- Exercise and diet
A. Assessment
Assessment is the first step in the nursing process. A large part of the job of a nurse is problem solving and clinical decision-making based on sound clinical judgment. Most problem solving tools suggest you collect all relevant data before you plan, predict, implement and evaluate your strategy to solve the problem.. Obtaining the patient’s health history is the first step in collecting data. This is called nursing assessment. Assessment involves collecting both subjective data and objective from patient. Subjective data will come from patient, family, off going nurse and other health care providers. Objective data are derived from medical record and nurse’s own physical assessment of the patient.
B. Diagnosis
Once assessment is completed, the nurse has the data to decide what priority healthcare needs must be addressed.
C. Planning
Outcomes or goals are then established to measure whether the nurse’s interventions have actually improved the patient’s health.
D. Implementation
The nurse then acts to assist the patient to meet the plan or goals set.
E. Evaluation
Finally the nurse reviews the outcomes to actually measure if goals were met. Changes to the goals or interventions are made to adjust to these measures.
Cultural factors in obtaining a health history
When interviewing a patient the nurse must be aware of cultural barriers and preferences in order to collect significant and complete subjective data.. For example due to age, culture, or ethnicity, some patients may believe that pain is to be expected and endured. The patient may not identify their pain as worthy of report unless the nurse is sensitive to this barrier in communication. Due to age, culture or ethnicity, some patients may feel uncomfortable discussing sexual health. In the DC area, HIV is epidemic, it is the nurse’s responsibility (along with all other healthcare personal) to uncover risk factors that can address safety and early treatment for STIs (sexually transmitted diseases). Culture can have many meanings. For example: one’s culture can be related to the gender you identify as, the religious group you grew up with, the parenting style you advocate. The nurse should not assume that, for example, the patient Maria Gomez, must be catholic since she has a latinex sounding name. The nurse must be open to learning about various cultures and ethnicity and comfortable initiating the conversation with the patient as to their particular practices and beliefs.
Health history and therapeutic communication
Have you ever been to see a healthcare provider and when they walk in the room they are not looking at you but are looking at the chart, or tapping on a computer. Have you ever felt rushed by their questions, like they are in a hurry and need to move on to the next patient? Have you ever had the healthcare provider give you a diagnosis, provide you with a treatment and you left with a prescription but you didn’t grasp the entire explanation? If you have experienced any of these scenarios, the healthcare provider may have provided less than ideal therapeutic communication skills.
Western culture has certain expectations related to therapeutic communication. For example, in the US, the following are usually acceptable:
- direct eye contact shows interest and care.
- Sitting at the same level as the patient shows respect and partnership.
- When asking questions that are sensitive in nature, you may have to preface your question with words of safety. such as: “Many people experiment with recreational drugs, we ask you about your possible use in order to be sure that whatever medicines we prescribe for instance will not interact with what you may already be taking to keep you safe.” “HIV is very common, there are many ways to prevent it and to treat it if we catch it early. What do you do to protect yourself from STI’s?” “If you have ever felt afraid with your loved ones, it is important that you ask for help, this is to protect you and to get resources for those you love.”
It is important to avoid medical jargon. “Have you experienced any syncope?” The patient will not understand that you are asking about symptoms of dizziness.
Timing is crucial: When someone is in pain, sleepy, scared, anxious, or confused the nurse will not obtain the most accurate and complete subjective data. The nurse may have to obtain what is of highest priority and wait for a better time to gain the rest of the relevant information. The nurse may have to ask questions slowly, repeat the question, and give the patient extra time to think and speak.
Open ended questions will encourage more open communication. Questions that can be answered by a “yes” or “no,” usually provide little insight into the patient’s condition. For example: “Do you have any stressor?” Most patients will answer the question they believe you want to hear, or the answer that will get them out of the office the quickest. An open ended version is “Tell me about the things in in your life right now that stress you.” The answer will surely open the conversation to further areas in the patients life and at the very least reveal challenges in the patient’s life that will require further assessment.
Closed ended questions may be necessary later in the interview. It is appropriate, at the right time, to ask the exact amount of acetaminophen the patient took before coming in or It is appropriate to ask if the patient has had this years flu shot (a yes or no question).
There are many cultural barriers to people utilizing and accessing health care. Some cultures believe that suffering is to be expected and embraced, or that complaining is “weak.” Some cultures are suspicious of western medicine. (i.e. due to the Tuskegee trials, and other abusive incidents, some African Americans do not trust that the western health care provider has their best interest in mind.) Some cultures, such as the LBBTQ community, have been mistreated by healthcare and therefore avoid access care. Those living in remote areas or lacking transportation may not be able to access healthcare. A patient who is subject to abuse, may avoid healthcare to keep the perpetrator undetected.
Example: health history
You will learn all the many components to collect a complete assessment. In order to ensure that you do not miss any important piece you will want to use a system to get organized . In n the following slide presentation you will find several forms that have been used by healthcare professionals to do just that. As you begin to learn the process it may help to use one of these forms. You will notice that most of the forms follow a similar pattern: It begins with basic demographics, then the chief complaint and thorough symptom analysis (OLDCARTS), past medical history, past surgical history, family history, social history and finally an inventory of potential health concerns each body system from head to toe (HEENT, Thorax, Cardiovasular, GI,GU, Integumentary, Musculoskeletal)
Open resources to enhance your knowledge of a comprehensive health history:
Documentation in Nursing: 1st Canadian edition
In clinical practice, documentation is an essential aspect of the nurses assessment. Nurses are held accountable for their actions. Medical records are proof of nurses’ actions as well. Therefore, if you acted but failed to document what you did, it is legally viewed as an inaction and the nurse can be held liable for negligence. The Affordable Care Act required all healthcare systems to institute electronic health records. Nurses are trained to properly and completely document all information they collect and all actions they complete. Nurses must also be proficient in electronic documentation systems.
The following is a resource to provide detailed information on documentation of health history.
References
LaPierre, D. (2010). Clinical assessment. Sharing in health.ca:open access training in healthcare.Retrieved at http://www.sharinginhealth.ca/clinical_assessment/clinical_assessment.html
Nursing Documentation https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/QMP/NurseDocumentationPPT.pdf
Taylor, C., Lillis, C., Lynn, P., & LeMone, P. (2015). Fundamentals of nursing: The art and science of person-centered nursing care(8th ed.). Philadelphia: Wolters Kluwer Health.
Wilson, S., Giddens, J., (2013). Health assessment for nursing
https://pressbooks.library.ryerson.ca/documentation/