Copyright 2002, Delmar, A division of Thomson Learning Chapter 3 The Complete Health History...
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Transcript of Copyright 2002, Delmar, A division of Thomson Learning Chapter 3 The Complete Health History...
Copyright 2002, Delmar, A division of Thomson Learning
Chapter 3
The Complete Health History Including Documentation
Copyright 2002, Delmar, A division of Thomson Learning
Competencies State the purpose of the four
different types of health history and provide an example of when each is used.
Identify the components of the complete health history.
Describe how to assess the ten characteristics of a chief complaint.
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Competencies Diagram a patient’s genogram correctly. Demonstrate sensitivity to patients of
different races, religions, ethnic backgrounds, sexual orientations, and socioeconomic status when conducting a health history.
Conduct a complete health history on ill and well patients and record data.
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Types of Health History Provides information on the
patient’s health status: social, emotional, physical, cultural, and spiritual identity
Complete health history Episodic health history Interval or follow-up health history Emergency health history
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Identifying Information Included in Medical Record Patient name Address Occupation Insurance Phone number
(continues)
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Identifying Information Included in Medical Record Usual source of health care Date of birth Birth place Emergency contact Social security number
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Complete Health History Patient profile Reason for seeking health care
Chief complaint (CC) Sign Symptom
Present health and history of present illness (HPI)
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Ten Characteristics of a Chief Complaint Location Radiation Quality Quantity Associated manifestations
Pertinent negatives
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Copyright 2002, Delmar, A division of Thomson Learning
Ten Characteristics ofa Chief Complaint Aggravating factors Alleviating factors Setting Timing Meaning and impact
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Past Health History (PHH) Provides information on the
patient’s health status from birth to present
Medical history Chronic illness Episodic illness Sequelae
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Past Health History Surgical history
Major procedures Minor procedures Include year performed, hospital,
physician, sequelae
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Past Health History Medications
Prescription Over-the-counter Herbs Home remedies General questions
Dose Frequency Side effects Purpose
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Past Health History Communicable diseases
Infectious Pertussis Tuberculosis Hepatitis AIDS
Sexually transmitted Gonorrhea Syphilis Chlamydia Herpes
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(continues)
Past Health History Allergies
Medications Food Animals Environment Symptoms Treatment Complications
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Past Health History Injuries/accidents Special needs Blood transfusions
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Past Health History Childhood illnesses
Varicella Diptheria Measles, mumps, rubella Polio, rheumatic or scarlet fever
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Past Health History Immunizations: childhood
MMR Polio Smallpox DPT Haemophilus influenza b (Hib) Hepatitis B
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Past Health History Immunizations: adult
Varicella Hepatitis A Hepatitis B Influenza Tetanus Pneumococcal Lyme Meningococcal Last TB test (date and results)
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Family Health History (FHH) Records the health status of the
patient and immediate blood relatives.
Contains age and health status of the patient, spouse, children, siblings, and the patient’s parents.
Document information in a genogram and in a list of familial diseases.
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Social History (SH) Records information about the
patient’s lifestyle that may impact health
Tips for obtaining information Establish rapport Direct eye-contact Pose questions in a matter of fact tone Nonjudgmental demeanor Normalizing
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Social History Alcohol use
Thorough assessment to include: Quantity of alcohol consumed Frequency of consumption Age at first drink Pattern of consumption Length of time consuming current amount History of loss of consciousness or
blackouts
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Social History Time of day when drinking occurs Drink alone or with others Drink and drive Self perception of drinking
CAGE questionnaire (Mayfield, McLeod & Hall, 1974) Have you ever felt you should cut
down on your alcohol intake?
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Social History Have people annoyed you by
criticizing your alcohol intake? Have you ever felt guilty about your
alcohol intake? Have you ever needed alcohol for an
eye-opener (morning consumption)? Tobacco use
Pack/year history Type of tobacco used
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Social History Age started to use tobacco Quantity used on daily basis Previous attempts to quit Self-perception of tobacco use Live or work with smoker
Drug use Prescription and over-the-counter
medications
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Social History Illegal and recreational drugs Same types of questions used for
determining alcohol use Sexual practices, specific questions Sexual orientation Past sexual practice Number of partners Birth control method
(continues)
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Social History Measures to prevent exchange of
body fluids Presence of STDs Satisfaction with sexual
performance/needs Travel history Work environment
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Social History Home environment
Physical Psychosocial
Hobbies or leisure activities Stress Education Economic status
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Social History Military service Religion Ethnic background Roles/relationships Functional health assessment
Activities of daily living
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Social History Health maintenance activities
(HMA) Sleep Diet Exercise Stress management Use of safety devices Health check-ups
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Review of Systems (ROS) Cephalo-caudal approach Questions
Sign/symptom related Disease related questions
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Documentation Guidelines Ensure accuracy
Record information immediately upon completion of patient encounter
Correct patient record or chart Avoid distractions while documenting Proofread your entry for accuracy and
completeness
(continues)
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Documentation Guidelines Date and time each entry Sign each entry with full legal name
and professional credentials Write legibly Use permanent ink (black preferred) Do not leave a space between
entries(continues)
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Documentation Guidelines Use quotes to indicate direct patient
response Document in chronological order Document in complete but concise
manner using phrases and abbreviations as appropriate
(continues)
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Documentation Guidelines Document telephone calls that relate
to the patient’s case Never correct another person’s entry Use a single line to cross out an
error, then date, time and sign correction
If it is not documented, it was not done
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Assessment-Specific Documentation Guidelines Record pertinent positive and negative
assessment data Document any parts of the assessment that
are omitted or refused by the patient Avoid using judgmental language Avoid evaluative statements; cite specific
statements or actions you observe(continues)
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Assessment-Specific Documentation Guidelines State time intervals precisely Use specific measurements Draw pictures when appropriate
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Assessment-Specific Documentation Guidelines Refer to findings using anatomic
landmarks Use the face of a clock to describe
findings that are in a circular pattern Document any change in the patient’s
condition during a visit or from previous visits
Describe what you observed, not what you did