basic health assessment: obtaining and documenting a comprehensive history

Basic Health Assessment:Obtaining and Documenting a

Comprehensive History

IMPORTANT!

• If you never touch this person, and spend all of your time getting a good history, you will be more likely to come up with the correct diagnosis than if you get a poor history and perform a fabulous physical exam!

Identifying Data

• Date• Name• Address• Phone Number• Gender• Date of Birth• Place of Birth• Age• Ethnic/racial background• Native language• Marital status

• Primary Care Provider• Specialists• Social security number• Insurance information• Religious preference• Education• Emergency contact• Occupation• Source of referral• Source and reliability of

interviewee• Dependents/caretaker

The Next Step

• Present illness

• History of Present Illness (HPI)

• Chief Complaint (CC)

• General Health

• Reason for Visit

ALL very similar – used interchangeably in some settings – can be confusing.

For our Purposes

• After the “Identifying Data”, you should proceed with the “Chief Complaint” which states, in the words of the care seeker, the reason for the visit. This may be one or more complaints or it may even just be “I’m here for a routine checkup!”

Questions

• Tell me what brings you here today?

• Describe for me the reason you came here today?

• What do you expect from your visit today?

• What’s troubling you today?

Next Step: History of the Present Illness

• Once you have the “Chief Complaint”, you can move into the “History of the Present Illness” or HPI.

• The HPI describes information relevant to the chief complaint(s).

• NOTE: You may not need the HPI if the person is just coming in for an annual exam with no complaints.

• You can think about the “Chief Complaint” as the title of the story and the “HPI” as the story itself .

Analysis of a Symptom: A Critical Step in Determining a Diagnosis!!

• Define the last time the person felt completely well. Sometimes people will confuse the first time they became concerned with a symptom as the onset of that symptom.

• There may also have been other symptoms associated with the primary symptom that preceded it, and forgotten.

Onset -Timing• A specific date and time is great, if you can get it!

Sometimes it’s helpful to associate symptoms with times in a persons life – birthdays, holidays etc.

• Where the person was at the time may also help in defining the dating.

• If possible, find out how the person felt just prior to the symptom.

• Was the onset sudden or gradual?• How long did this symptom last?• How frequent is it experienced? Number of times per

hour, week, day, month?• Again, important to narrow this down as much as

possible, go slowly – it’s that important!!

Precipitating Factors

Character of the SymptomThis is a description that best describes the

symptom, from the persons perspective. Always try and have the person describe it first – then, if necessary ask questions.

For example: Pain – Is it throbbing, crushing, burning, sharp, dull, stabbing, squeezing

Another example: Shortness of breath – is it air hunger, suffocating, gasping

Another example: Fatigue – is it complete exhaustion, is it lack of interest, is it incapacitating

Location

• Ask the person to identify the location(s) of the symptom – understanding that there may be symptoms in multiple sites or referred.

• Identify:

• Can it be pinpointed, are there radiation patterns, is it generalized, vague?

Quantity or Severity

• Again, try and get specific information.

For example: if it’s pain, can they describe the severity on a scale of 1-10?

Another example: nausea – how often does it occur?

Another example: headache – how severe is it - are you able to function or do you have to go to bed?

Setting

• What is the person doing and/or where is she when she experiences this symptom?

Again, associating the symptom with some aspect of the persons life could be helpful –are you okay when you first get up in the morning? Are you active or passive when you notice it?

Factors that Aggravate or Relieve

• Sometimes people are good historians with this info but often they are not! Don’t be surprised if they are vague in response to this question: what makes it better – what makes it worse?

• Common influencing factors: exercise, excitement, meals, medication, smoking, standing, bending over, cold or hot environment, fatigue, time of day or season.

• A symptom diary is often the best way to get a handle on this as well as the other elements associated with the symptom analysis.

Efforts to Treat

• Home remedies (what and when)

• Body positions (e.g. bed rest)

• Over-the-counter medications

• Prescription medications

• Visits to other health care providers

Associated symptoms

• This refers to other symptoms that are going on at the same time – not the primary symptoms.

• Sometimes it’s as easy as severe headache with associated nausea and/or vomiting.

• Other times it’s not so obvious and may come out later during the Review of Systems (ROS).

Clients Perception and Impact on Quality of Life

• In all of my years of experience, I have found that the woman herself usually has a strong, innate, intuitive sense of what is causing her symptoms! Never fail to ask this questions:

What do you think is causing this problem?OrAny ideas about why this is happening to

you?

Putting a Symptom Analysis Together: One example

CC: Chest PainHPI: Crushing, heavy, substernal pain, radiating to

left shoulder and arm which causes the woman to stop all activity, occurring for past three months at about 7-10 day intervals, each attack being only 1-2 minutes in duration. Often occurs about an hour after meals, especially while walking. Also brought on by severe job tension, cold weather, large meal, climbing two flights of steps. Relieved by stopping activity. Associated with sweating of few minutes duration and fear of death. Does not recall if she is short of breath.

Past History

Components of “Past History”

1. Childhood Illnesses

2. Adult Illnesses (serious and chronic illnesses)

3. Psychiatric Illnesses

4. Accidents and Injuries

5. Operations

6. Hospitalizations

7. Obstetrical History

Childhood Illnesses

Ask if she has had any of the following:

Measles, mumps, rubella, chicken pox, pertussis, strep throat, rheumatic fever, scarlet fever, poliomyelitis, asthma.

Obtaining dates may be difficult – especially if someone is 65 or over …..however, if the person is 18, this could be more significant.

Also note severity and/or complications, if indicated.

Adult Illnesses

Diabetes, hypertension, heart disease, cancer, seizure disorders, kidney problems, blood disorders………..basically, you are asking about major body systems and hoping that the person has some memory of this, which again, is dependent on how old they are and how many medical illnesses they may have already experienced!

No Need to Write a Story!

In any of these categories, I am not looking for a narrative! In fact, just the opposite. This is the right time and place to eliminate verbs and write in phrases rather than sentences

Example: Pneumonia, right, 1966; cholecystitis, 1969, no attacks since, no stones.

Important to Remember

The lists of adult illness are those that have been DIAGNOSED……..this section of the health history is NOT for the purpose of exploring other symptoms that the person may have had or has presently. We’ll get to that in the Review of Systems (ROS).

Psychiatric Illnesses

Ask if the person has ever been diagnosed

with depression, anxiety, schizophrenia, mood disorders, personality disorders.

AGAIN, be careful here – someone may say they have been depressed in the past, however, if it was not diagnosed and/or treated, it does not belong in this section!

Accidents and Injuries

As usual, you are looking for the dating and the details of the injury. However, just as important is the context of the accident.

For instance, if a person had an accident and fell in her apartment – resulting in a fractured hip, you would also want to know if she was dizzy, did she trip over a rug, did she loose consciousness, was it a spontaneous fracture?

IMPT: head injuries, burns, other trauma

Operations

Here is what you need to know:

What, where, when, why, and by whom.

Example: Hysterectomy, 1972 for prolonged bleeding due to fibroids, Overlook Hospital, NJ, no malignancy reported.

Hospitalizations

• Do NOT include anything that you have already covered under accidents or operations.

• Provide reason for, location, health care provider, duration.

Example: Exacerbation of systemic lupus with kidney involvement, Cornell Medical Center, Dr. Zacchary, in-patient treatment with IV steroids for 5 days.

Obstetrical History

• Complete pregnancies: number, pregnancy course, postpartum course, condition, weight and sex of each child

• In Complete pregnancies: duration, termination, circumstances (including abortions and stillbirths)

• Summary of Complications

CURRENT HEALTH STATUS

• Allergies• Immunizations• Screening Tests• Environmental

Hazards• Use of Safety

Measures• Exercise and leisure

activities

• Sleep patterns• Diet• Current Medications• Tobacco• Alcohol/Illicit drug

history• Foreign Travel• Sexual Activity

Allergies

• Medication, food, environmental agents. Indicate type of reaction – rash, edema etc.

NOTE: It’s always important to clarify this- so many people think they have allergies, when in fact, they may just be “sensitivities” that do not put them at serious risk. Example: rashes from sulfa or ampicillin – usually do not represent “true” allergies.

Immunizations

• Childhood immunizations: measles, mumps, rubella, polio, diptheria, pertussis, tetanus.

• Note last tetanus booster

• Last flu shot

• Pneumococcal vaccine, if indicated

• Hepatitis B

Screening Tests

• Last pap smear and result

• Last mammogram, if indicated, and result

• Lipid screen and result

• Test of stool for occult blood and result

• Sigmoidoscopy or colonoscopy if indicated

• The most recent physical, dental, vision, hearing, ECG, and chest x-ray.

Environmental Hazards

• Examples of employment hazards: inhalants, noise, heavy lifting, psychological stress,machinery.

• Examples of hazards in the home: fire, stairs to climb, inadequate heat, open gas heaters, inadequate toilet facilities, concern about pest control, inadequate space.

• Examples of neighborhood hazards: noise, water and air pollution, inadequate police protection, heavy traffic, overcrowding, isolation from neighbors.

• Examples of community hazards: unavailability of stores, market, laundry facilities, drug stores, no access to bus line

NOTE

Women who work at home have been found to have high levels of exposure to various toxic cleaning agents….something to think about!

ALSO – note if there are smokers in the home, school or work environments

Use of Safety Measures

• Seat belts – actually it’s been found that regular seat belt use is a predictor for engaging in other valuable health promotion activities!

• Car seats for children

• Shower handles for the disabled or the elderly

Exercise and Leisure Activities

• Indicate what, if anything, the person is doing for exercise…….whether formal or informal. For example: in NYC, walking is a necessity and also serves as a form of exercise.

• Identifying both exercise and leisure activities helps to highlight potential risks for injury while also indicating attempts to modify risks for cardiac and bone disease.

Sleep Patterns

• Identify how many hours per night the person sleeps

• Indicate whether or not the person has difficulty getting or staying asleep

• Indicate if there is difficulty breathing during sleep or if there is noticeable snoring

• Indicate if the person is tired during the day in spite of getting enough perceived sleep

Diet• Attempt to get a 24 hour recall• Include beverages and snacks• Determine if this is a usual diet• Indicate whether there are food

“sensitivities”• Note amount of caffeine intake per day• Indicate changes in appetite• Special diets

Current Medications

• Begin with the last 24 hours and include prescription drugs, non prescription drugs, vitamin and mineral supplements, home remedies, homeopathic and herbal products.

• Ask about borrowed medicines• Include names, dose, schedule, duration and

reason for use.• Note: I often ask a person to bring everything

that they take when they come for their first visit – amazing what you can find!

Tobacco, Alcohol and Illicit Drugs

• Include type, amount, duration and pattern of use.

• Indicate if exposure to second hand smoke.• There is a tendency to underestimate, especially

for alcohol use. Identify the type of alcohol generally consumed first, then estimate the amount taken.

• Indicate if alcohol is used to modify stress.• Drinking companions or alone

Foreign Travel

• Especially important these days – as noticed by the SARS outbreak.

• However, also important in terms of GI complaints – many countries have parasites in the drinking water that can easily go undiagnosed for quite awhile, once a person returns.

Sexual Activity

• Sexual orientation, level of activity, use of contraceptives, problems

• Question regarding sexual violence.

• A comprehensive sexual history is conducted only if there are indications of a problem. (You will learn that in Advanced Health Assessment)

FAMILY HISTORY

Common disorders found in families:

• Hyperlipidemia• Heart Disease• Diabetes Mellitus• Hypertension• Myopia• Kidney Disease

• Cancer (bowel, ovarian and breast)

• Osteoporosis• Mental Illness• Alcoholism• Arthritis• Epilepsy• Anemias

Focus

• Age and health OR age and cause of death, of grandparents, parents, siblings and children.

• NO need to get into aunts and uncles etc.

• Note if adopted or born via AI

• Can document using a Genogram

PSYCHOSOCIAL HISTORY

Components1. Home situation2. Significant others3. Support Systems 4. History of Interpersonal Trauma5. Daily life6. Important experiences7. Religious beliefs8. Outlook on the present/future

Home Situation

• Urban, rural, suburban

• Alone, with family members, with others

• Number of rooms

• Number and ages of other individuals in home

• Feelings about home arrangements

Significant Others

• Informal support systems: family, friends, neighbors.

• Most significant relationship in and out of the home.

• Who does this person turn to when they need help?

Support Systems

• Formal support systems: WIC, Medicare, Medicaid, Meals on wheels, Food stamps, SSI

• Semi formal support systems: School, church, clubs

• Indicate satisfaction with social contacts

History of Interpersonal Trauma

• Inquire about rape, incest, abuse as a child or spouse, other personal tragedies.

• Ease in discussion.

• Stage of resolution (denial, fear, anger, adaptation).

• Resources.

• Always ask: Is anyone hurting you?

Daily Life

• General description of work, leisure and rest

• Hobbies and/or methods of relaxation

• Community activities and involvement

Important Experiences

Ask this as an open ended sentence, you will learn a great deal about a person!

Examples of some commonly shared experiences that could have implications for health include: school, military service, work, marriage, childbearing, retirement.

Religious Beliefs

• Religious practices and rituals

• Spiritual advisors

• Association between religious beliefs and state of health

• Relationship with an organized religious group

Outlook on the Present/Future

• How does this person feel about her life now?

• Where does she see herself in 1 year, 5 years?

• Is she optimistic?

• Is she pessimistic?

• Is she hopeful?

REVIEW OF SYSTEMS (ROS)

Of all the components in the health history, this is the one that most nurses find confusing……so take some time to understand what this is about!

It’s best to begin the ROS with an explanation – so the person has some idea of why you are asking all these questions when she came in with a CC of say, fatigue .

What is the ROS?

• The ROS is a review of all current and pertinent past symptoms, in order to be sure that no pertinent clues have been missed by either the provider or the care seeker.

• There is no practical limit or list of questions which might be asked….it’s somewhat arbitrary, based on the individual situation. For instance, you would not ask a 65 year old woman, the same questions you would ask a 22 year old postpartum mom.

• The questioning proceeds in roughly anatomical order so there is some sort of systematic approach.

More ROS• As much as possible, do not use medical jargon

because that would defeat the purpose!• When you get a positive response, ask for

further information: “tell me more” or “tell me about that”.

• Don’t be surprised if you uncover something that belongs in the family history, or hospitalization section….sometimes this line of questioning jars the memory. If this occurs, do not document this in the ROS but rather in the appropriate section.

ROS Handout

Refer to the handout titled, Review of Systems.

The questions on the left are phrased in lay terminology, as much as possible, according to system.

The right side is intended for you, the practitioner, to be mindful of what you might be looking for when asking these questions.

Documenting the Health History

• First and foremost, this is NOT a short story narrative!

• The history should be brief and to the point, stating only and everything that is important.

• An organized systematic approach, using specific headings, makes it easy for the reader to extrapolate data without reading the entire report. For instance, if I just want to check the family history, I should be able to find it easily and quickly.

Review – Major Components of a Comprehensive Health History

• Identifying data• Chief complaint (CC)• History of Present Illness (HPI)• Past History• Current Health Status• Family History• Psychosocial history• Review of Systems

Helpful Study Hints

• Get some index cards

• Write the category of the health history on one side (ex. Psychosocial hx)

• On the other side, write the components of that category that should be addressed

• For the Review of Systems, you may need more than one card!

More Study Hints

• Once you feel you know the components of the history, find a volunteer who can spend about one hour with you. Go through a mock history with this person – without using any cards or prompts!! Use the self assessment checklist to see what you remembered and what you may have forgotten.

• This is important, because it will tell you the kinds of questions that you do not ask – and it is a great way to learn . It also helps you to fine tune your interview skills.

Sample History

• A sample history is included in this packet. This will provide you with a framework to document your findings.

Required Paper for this Program

• When you are ready, conduct and document a comprehensive health history with someone who has minimal health concerns and can spend at least one hour with you.

• Before sending me this history, use the enclosed self assessment sheet and correct what is missing. Send a copy of the self assessment sheet as well.

• NOTE: It’s best to complete this part of the required material BEFORE proceeding to the physical assessment section!