Components of a Health History for the beginning nursing student

1. COMPONENTS OF A
HEALTH HISTORY
NUR 226
Health Assessment

2. WHY DO WE GATHER DATA?

3. SUBJECTIVE DATA
 Documentation takes many different forms

4. COMPONENTS OF A HEALTH HISTORY
1. Demographic data
a. Name & Address
b. Billing & insurance information
c. Emergency contact & religious contact
d. Primary language
2. Reasons for seeking care
a,. Statement in the patients own words
3. History of present illness
a. Ask additional questions to get more detail
b. What makes it worse, what makes it better??

5. HEALTH HISTORY….

6. COMPONENTS, CONTINUED
4. Past Health History
a. medical diagnoses
b. surgical procedures
5. Current medications and indications for use
a. prescriptions: dose, frequency and route
b. over-the-counter medcations
c. vitamin supplements
6. Family History
a. health of parents, siblings, children

8. COMPONENTS, CONTINUED
7. Functional Health Assessment
a. self care or activities of daily living
b. checklist
8. Growth & Development
a. benchmarks for growth
b. psycho-social aspects
9. Review of Systems
a. head-to-toe list
b. cardiac, respiratory, etc

10. COMPONENTS OF A HEALTH HISTORY
 Good questioning skills
 Open ended questions
 Best patient outcome