Exam (elaborations)
NR 302-Week 3 Edapt Health History.
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NR 302-Week 3 Edapt Health History.
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Health HistorySign Versus Symptom
A sign is an objective abnormal assessment finding detected on physical examination or through diagnostic testing.
A symptom is a subjective feeling a client has that is associated with a disorder.
Health History Components
A health history component may include biographic data, the reason for seeking care, present health or history of present
illness, past history, medication reconciliation, family history, review of systems, functional assessment, developmental
assessment, and cultural assessment.
Skin inspection and vital sign assessment are completed as part of the physical assessment, not the health history.
Review of Systems
The purpose of the review of systems is to evaluate each body system to uncover dysfunction or disease. Asking about a
client’s vision provides information about their eye health, which is part of the sensory system.
The other questions provide information about other aspects of the health history
General Overall Health State: "I have gained 5 pounds in the last month."
Health Promotion: "My last ECG was in 2015."
Cardiovascular: "I have no chest pain."
Neurologic System: "I sometimes have headaches."
Gastrointestinal: "I have had no change in appetite."
Respiratory: "I do not have shortness of breath."
What is a Health History?
A health history is a comprehensive record of a client's past and present health status.
A comprehensive health history is usually collected during the client's first visit.
A focused health history is completed when a client presents with a specific problem.
The health history includes biographic data, the reason for seeking care, present health or history of present illness, past
history, medication reconciliation, family history, review of systems, and functional assessment.
The most accurate history is furnished by the client or an interpreter. Less accurate sources include friends or family.
Biographical Data
Biographical data is information about a person's identity. The data may vary by facility and is collected using a form. Biographical
data may include, but is not limited to:
full name
address
phone number
age and birth date
birthplace
sex
marital status
social security number
race and ethnic origin
occupation
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, source of this information (usually the person seeking care but may be a parent, guardian, or interpreter)
History of Present Illness
investigating the history of present illness or health is one of the most important steps in the health history process. The
purpose is to collect as much data about the reason for seeking care as possible and to document it in a narrative format.
Past History
Gathering data regarding a client's past health history can assist the examiner in clinical decision making. The information
provided can provide cues to current health issues. The history can also indicate what health issues the client may be at risk
for in the future.
Past health history topics include childhood illnesses, accidents or injuries, chronic illnesses, hospitalizations and surgeries,
immunizations, last examination dates, allergies, and obstetric history for women.
Medication Reconciliation
Medication reconciliation is the process of comparing the medications prescribed with the medications the client is taking (Sen
et al., 2014). Medications include prescriptions, over-the-counter drugs, and herbal supplements. It is important to record the
name, dosage, frequency, route, and purpose. The examiner will review the list and address duplications, omissions,
interactions, and the need to continue the medication.
Medications include prescriptions, over-the-counter drugs, and herbal supplements.
Alcohol, tobacco, and recreational drugs are not included.
Medication reconciliation is producing an accurate list of all medications a client is taking and comparing that list against the
healthcare provider's orders.
Drug testing, drug recall, and medication examination are not used when reconciling medications the client is currently taking.
Functional Assessment
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