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Practical Nursing Diploma Program Semester 1 The Health History Interview Orienting the patient……... • to the surroundings • to the rules • to the team members they may come in contact with • to the resources available - kitchen, showers etc. • to the plan of care Why do we do this????? • if we’re going to help the patient, we need to know as much about him/her as possible • the health history interview accomplishes that objective • once completed, the document is placed on the chart so that other team members can review it • can reduce repetition of questions to • discharge planning begins on admission - we need to know if this patient is going to be able to go back to the same environment post hospitalization or if he will need support systems • if help will be needed, the process can start early to avoid unnecessary delays on discharge Information to be gathered……. • Vital signs, height, weight • medical history - illnesses, hospitalizations • allergies • current medications • current symptoms • next of kin • head to toe assessment • does he have a power of attorney for personal care, Living will?? • religious preferences re food, blood etc. • all forms differ but most include the same types of information • information can be gathered from: the patient, the family, old charts, other team members, family doctor Personal belongings…….. • valuables should be locked up with security • follow hospital protocol • encourage patient to send home valuables with family members if present: storage is an issue • document things like dentures, hearing aids, personal walkers etc.