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Chapter 3
The Complete Health
History Including
Documentation
Copyright 2002, Delmar, A division of Thomson Learning
Competencies
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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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Copyright 2002, Delmar, A division of Thomson Learning
Competencies
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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.
Copyright 2002, Delmar, A division of Thomson Learning
Types of Health
History
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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
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Patient name
Address
Occupation
Insurance
Phone number
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Identifying Information
Included in Medical
Record
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Usual source of health care
Date of birth
Birth place
Emergency contact
Social security number
Copyright 2002, Delmar, A division of Thomson Learning
Complete Health
History
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Patient profile
Reason for seeking health care
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Chief complaint (CC)
Sign
Symptom
Present health and history of present
illness (HPI)
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Ten Characteristics of
a Chief Complaint
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Location
Radiation
Quality
Quantity
Associated manifestations
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Pertinent negatives
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Ten Characteristics of
a Chief Complaint
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Aggravating factors
Alleviating factors
Setting
Timing
Meaning and impact
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Past Health History
(PHH)
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Provides information on the
patient’s health status from birth to
present
Medical history
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Chronic illness
Episodic illness
Sequelae
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Past Health History
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Surgical history
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Major procedures
Minor procedures
Include year performed, hospital,
physician, sequelae
(continues)
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Past Health History
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Medications
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Prescription
Over-the-counter
Herbs
Home remedies
General questions
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Dose
Frequency
Side effects
Purpose
(continues)
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Past Health History
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Communicable diseases
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Infectious
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Pertussis
Tuberculosis
Hepatitis
AIDS
Sexually transmitted
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Gonorrhea
Syphilis
Chlamydia
Herpes
(continues)
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Past Health History
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Allergies
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Medications
Food
Animals
Environment
Symptoms
Treatment
Complications
(continues)
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Past Health History
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Injuries/accidents
Special needs
Blood transfusions
(continues)
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Past Health History
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Childhood illnesses
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Varicella
Diptheria
Measles, mumps, rubella
Polio, rheumatic or scarlet fever
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Past Health History
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Immunizations: childhood
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MMR
Polio
Smallpox
DPT
Haemophilus influenza b (Hib)
Hepatitis B
(continues)
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Past Health History
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Immunizations: adult
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Varicella
Hepatitis A
Hepatitis B
Influenza
Tetanus
Pneumococcal
Lyme
Meningococcal
Last TB test (date and results)
Copyright 2002, Delmar, A division of Thomson Learning
Family Health History
(FHH)
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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.
Copyright 2002, Delmar, A division of Thomson Learning
Social History (SH)
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Records information about the
patient’s lifestyle that may impact
health
Tips for obtaining information
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Establish rapport
Direct eye-contact
Pose questions in a matter of fact tone
Nonjudgmental demeanor
Normalizing
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Social History
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Alcohol use
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Thorough assessment to include:
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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
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Social History
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Time of day when drinking occurs
Drink alone or with others
Drink and drive
Self perception of drinking
CAGE questionnaire (Mayfield,
McLeod & Hall, 1974)
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Have you ever felt you should cut
down on your alcohol intake?
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Copyright 2002, Delmar, A division of Thomson Learning
Social History
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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
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Pack/year history
Type of tobacco used
(continues)
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Social History
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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
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Prescription and over-the-counter
medications
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Social History
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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)
Copyright 2002, Delmar, A division of Thomson Learning
Social History
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Measures to prevent exchange of
body fluids
Presence of STDs
Satisfaction with sexual
performance/needs
Travel history
Work environment
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Social History
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Home environment
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Physical
Psychosocial
Hobbies or leisure activities
Stress
Education
Economic status
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Social History
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Military service
Religion
Ethnic background
Roles/relationships
Functional health assessment
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Activities of daily living
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Social History
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Health maintenance activities
(HMA)
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Sleep
Diet
Exercise
Stress management
Use of safety devices
Health check-ups
Copyright 2002, Delmar, A division of Thomson Learning
Review of Systems
(ROS)
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Cephalo-caudal approach
Questions
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Sign/symptom related
Disease related questions
Copyright 2002, Delmar, A division of Thomson Learning
Documentation
Guidelines
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Ensure accuracy
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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)
Copyright 2002, Delmar, A division of Thomson Learning
Documentation
Guidelines
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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)
Copyright 2002, Delmar, A division of Thomson Learning
Documentation
Guidelines
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Use quotes to indicate direct patient
response
Document in chronological order
Document in complete but concise
manner using phrases and
abbreviations as appropriate
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Documentation
Guidelines
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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
Copyright 2002, Delmar, A division of Thomson Learning
Assessment-Specific
Documentation
Guidelines
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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)
Copyright 2002, Delmar, A division of Thomson Learning
Assessment-Specific
Documentation
Guidelines
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State time intervals precisely
Use specific measurements
Draw pictures when appropriate
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Assessment-Specific
Documentation
Guidelines
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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
Copyright 2002, Delmar, A division of Thomson Learning